Fall-Risk Increasing Drugs (FRIDs) are an important and modifiable fall-risk factor. A Clinical Decision Support System (CDSS) could support doctors in optimal FRIDs deprescribing. Understanding ...barriers and facilitators is important for a successful implementation of any CDSS. We conducted a European survey to assess barriers and facilitators to CDSS use and explored differences in their perceptions.
We examined and compared the relative importance and the occurrence of regional differences of a literature-based list of barriers and facilitators for CDSS usage among physicians treating older fallers from 11 European countries.
We surveyed 581 physicians (mean age 44.9 years, 64.5% female, 71.3% geriatricians). The main barriers were technical issues (66%) and indicating a reason before overriding an alert (58%). The main facilitators were a CDSS that is beneficial for patient care (68%) and easy-to-use (64%). We identified regional differences, e.g., expense and legal issues were barriers for significantly more Eastern-European physicians compared to other regions, while training was selected less often as a facilitator by West-European physicians. Some physicians believed that due to the medical complexity of their patients, their own clinical judgement is better than advice from the CDSS.
When designing a CDSS for Geriatric Medicine, the patient's medical complexity must be addressed whilst maintaining the doctor's decision-making autonomy. For a successful CDSS implementation in Europe, regional differences in barrier perception should be overcome. Equipping a CDSS with prediction models has the potential to provide individualized recommendations for deprescribing FRIDs in older falls patients.
Background: Proinflammatory mediators such as the cysteinyl leukotrienes are important in the pathophysiology of allergic rhinitis. This study evaluated the efficacy and tolerability of montelukast, ...a cysteinyl leukotriene receptor antagonist, given once daily in the morning for treatment of seasonal (fall) allergic rhinitis for 4 weeks.
Methods: This was a randomized, double‐blind trial with a placebo run‐in and a 4‐week treatment period. Patients (n = 1079) with a history of allergic rhinitis and a positive skin test to seasonal pollen allergens were assigned to placebo, montelukast 10 mg, or loratadine 10 mg. Symptoms were assessed with a daily diary.
Results: Montelukast was more effective than placebo in improving scores for the primary endpoint of daytime nasal symptoms (P = 0.003) and the secondary endpoints of night‐time, composite, and daytime eye symptoms, patient's and physician's global evaluations of allergic rhinitis, and rhinoconjunctivitis quality‐of‐life (P ≤ 0.006). The positive control loratadine also improved scores for the primary endpoint (P ≤ 0.001) and the majority of the secondary endpoints (P < 0.03). When analyzed by week, the treatment effect of montelukast was more persistent than loratadine over all 4 weeks of treatment.
Conclusion: Montelukast provided effective relief of seasonal allergic rhinitis symptoms when given once daily in the morning, showed significant and sustained improvement in symptoms of allergic rhinitis over 4 weeks of treatment, and was well‐tolerated.
Histamine and cysteinyl leukotrienes seem to be important mediators of allergic rhinitis.
This multicenter, randomized, double-blind, parallel-group, placebo-controlled trial evaluated the ...effectiveness and tolerability of montelukast, loratadine, and combination therapy with montelukast and loratadine for treating patients with fall seasonal allergic rhinitis.
After a 1-week, single-blind, placebo run-in period, 907 male and female patients aged 15 to 82 years were randomized to 1 of 4 treatments: montelukast 10 mg (n = 155), loratadine 10 mg (n = 301), combination montelukast 10 mg and loratadine 10 mg (n = 302), or placebo (n = 149), administered once daily at bedtime for 2 weeks. The primary endpoint was the daytime nasal symptoms score (mean of congestion, rhinorrhea, pruritus, and sneezing).
Mean symptom scores at baseline were similar for the four treatment groups. For each of the three active treatments, the difference was significant for the mean change from baseline compared with placebo (P < or = 0.001). However, the effect of montelukast/loratadine compared with loratadine alone, the primary comparison, was not significantly different. Differences for each therapy alone compared with placebo were also significant for most secondary endpoints, including nighttime symptom scores, eye symptoms scores, and rhinitis-specific quality of life. Differences for montelukast/loratadine compared with each therapy alone generally showed numerical superiority, and a few endpoints showed differences that were statistically significant. All active treatments showed a safety profile generally similar to placebo.
Montelukast alone or in combination with loratadine is well tolerated and provides clinical and quality-of-life benefits for patients with seasonal allergic rhinitis.
Key summary points
Aim
To summarize the falls-related risks of cognitive enhancing medications used to treat neurodegenerative conditions. To assist the clinician in considering the appropriateness ...of prescribing a cognitive enhancer in an older person at risk of falls and explore the factors that should be considered when reviewing the ongoing use of these medications.
Findings
Cognitive enhancer use is associated with multiple fall-related side effects, particularly in the initial weeks of administration and up-titration. Acetylcholinesterase inhibitors and memantine differ in their fall-related side effect profiles. Cognitive enhancers can contribute to falls through precipitating cardiac, sleep, neurological (e.g. seizure), extrapyramidal, bladder and/or neuro-psychiatric side effects. Cognitive enhancers should be subject to frequent medication review, including appropriate treatment indication and occurrence of side effects. Several suggested guidelines exist to aid deprescribing decisions, however, these are based on a relatively small number of focused clinical trials.
Message
An individualised approach should be taken when considering whether cognitive enhancer therapy is still appropriate in older adults at risk of falling. Clinicians should consider the plethora of risks associated with (de-) prescribing these medications.
Purpose
Cognitive enhancers are the primary pharmacological therapy prescribed to those with dementia, comprising of memantine and the acetylcholinesterase inhibitors (AChEIs). The long-term cognitive and behavioural benefits of these medications, as well as their potential contribution to falls is currently debated, with recent Delphi studies being unable to reach consensus on whether these medications should be deprescribed. In this narrative clinical review, as part of a series on deprescribing in people at risk of falls, we explore the potential falls-related side effects experienced in people taking cognitive enhancers, alongside situations where deprescribing may be appropriate.
Methods
We undertook a literature search of PubMed and Google Scholar, using terms capturing falls and cognitive enhancers, as well as consulting the British National Formulary and published Summary of Medicinal Product Characteristics. These searches informed the subsequent clinical review.
Results
Cognitive enhancers should be subject to regular review, including confirmation of appropriate treatment indication, and occurrence of side effects in the context of falls. AChEIs, in particular, are associated with a broad range of side effects that can contribute to increased falls risk. These include bradycardia, syncope and neuromuscular effects. Where these have been identified, deprescribing should be considered, as well as alternative treatment options. Deprescribing studies have shown mixed results, likely due to considerable methodological heterogeneity. Several suggested guidelines exist to aid deprescribing decisions, many of which are highlighted in this review.
Conclusions
The use of cognitive enhancers should be regularly reviewed and decisions to deprescribe made on a case-by-case basis, considering both the risks and benefits of stopping these medications.
The protonic ceramic electrochemical cell (PCEC) is an emerging and attractive technology that converts energy between power and hydrogen using solid oxide proton conductors at intermediate ...temperatures. To achieve efficient electrochemical hydrogen and power production with stable operation, highly robust and durable electrodes are urgently desired to facilitate water oxidation and oxygen reduction reactions, which are the critical steps for both electrolysis and fuel cell operation, especially at reduced temperatures. In this study, a triple conducting oxide of PrNi
Co
O
perovskite is developed as an oxygen electrode, presenting superior electrochemical performance at 400~600 °C. More importantly, the self-sustainable and reversible operation is successfully demonstrated by converting the generated hydrogen in electrolysis mode to electricity without any hydrogen addition. The excellent electrocatalytic activity is attributed to the considerable proton conduction, as confirmed by hydrogen permeation experiment, remarkable hydration behavior and computations.
Abstract Falls in Parkinson's disease (PD) are common and frequently devastating. Falls prevention is an urgent priority, but there is no accepted program that specifically addresses the risk profile ...in PD. Therefore, we aimed to provide consensus-based clinical practice recommendations that systematically address potential fall risk factors in PD. We developed an overview of both generic (age-related) and PD-specific factors. For each factor, we specified: best method of ascertainment; disciplines that should be involved in assessment and treatment; and which interventions could be engaged. Using a web-based tool, we asked 27 clinically active professionals from multiple relevant disciplines to evaluate this overview. The revised version was subsequently reviewed by 12 experts. Risk factors and their associated interventions were included in the final set of recommendations when at least 66% of reviewing experts agreed. These recommendations included 31 risk factors. Nearly all required a multidisciplinary team approach, usually involving a neurologist and PD-nurse specialist. Finally, the expert panel proposed to first identify the specific fall type and to tailor screening and treatment accordingly. A routine evaluation of all risk factors remains reserved for high-risk patients without prior falls, or for patients with seemingly unexplained falls. In conclusion, this project produced a set of consensus-based clinical practice recommendations for the examination and management of falls in PD. These may be used in two ways: for pragmatic use in current clinical practice, pending further evidence; and as the active intervention in clinical trials, aiming to evaluate the effectiveness and cost-effectiveness of large scale implementation.
Abstract
Background
falls and fall-related injuries are common in older adults, have negative effects both on quality of life and functional independence and are associated with increased morbidity, ...mortality and health care costs. Current clinical approaches and advice from falls guidelines vary substantially between countries and settings, warranting a standardised approach. At the first World Congress on Falls and Postural Instability in Kuala Lumpur, Malaysia, in December 2019, a worldwide task force of experts in falls in older adults, committed to achieving a global consensus on updating clinical practice guidelines for falls prevention and management by incorporating current and emerging evidence in falls research. Moreover, the importance of taking a person-centred approach and including perspectives from patients, caregivers and other stakeholders was recognised as important components of this endeavour. Finally, the need to specifically include recent developments in e-health was acknowledged, as well as the importance of addressing differences between settings and including developing countries.
Methods
a steering committee was assembled and 10 working Groups were created to provide preliminary evidence-based recommendations. A cross-cutting theme on patient’s perspective was also created. In addition, a worldwide multidisciplinary group of experts and stakeholders, to review the proposed recommendations and to participate in a Delphi process to achieve consensus for the final recommendations, was brought together.
Conclusion
in this New Horizons article, the global challenges in falls prevention are depicted, the goals of the worldwide task force are summarised and the conceptual framework for development of a global falls prevention and management guideline is presented.
With the global population aging, falls and fall-related injuries are ubiquitous, and several clinical practice guidelines for falls prevention and management for individuals 60 years or older have ...been developed. A systematic evaluation of the recommendations and agreement level is lacking.
To perform a systematic review of clinical practice guidelines for falls prevention and management for adults 60 years or older in all settings (eg, community, acute care, and nursing homes), evaluate agreement in recommendations, and identify potential gaps.
A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analyses statement methods for clinical practice guidelines on fall prevention and management for older adults was conducted (updated July 1, 2021) using MEDLINE, PubMed, PsycINFO, Embase, CINAHL, the Cochrane Library, PEDro, and Epistemonikos databases. Medical Subject Headings search terms were related to falls, clinical practice guidelines, management and prevention, and older adults, with no restrictions on date, language, or setting for inclusion. Three independent reviewers selected records for full-text examination if they followed evidence- and consensus-based processes and assessed the quality of the guidelines using Appraisal of Guidelines for Research & Evaluation II (AGREE-II) criteria. The strength of the recommendations was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation scores, and agreement across topic areas was assessed using the Fleiss κ statistic.
Of 11 414 records identified, 159 were fully reviewed and assessed for eligibility, and 15 were included. All 15 selected guidelines had high-quality AGREE-II total scores (mean SD, 80.1% 5.6%), although individual quality domain scores for clinical applicability (mean SD, 63.4% 11.4%) and stakeholder (clinicians, patients, or caregivers) involvement (mean SD, 76.3% 9.0%) were lower. A total of 198 recommendations covering 16 topic areas in 15 guidelines were identified after screening 4767 abstracts that proceeded to 159 full texts. Most (≥11) guidelines strongly recommended performing risk stratification, assessment tests for gait and balance, fracture and osteoporosis management, multifactorial interventions, medication review, exercise promotion, environment modification, vision and footwear correction, referral to physiotherapy, and cardiovascular interventions. The strengths of the recommendations were inconsistent for vitamin D supplementation, addressing cognitive factors, and falls prevention education. Recommendations on use of hip protectors and digital technology or wearables were often missing. None of the examined guidelines included a patient or caregiver panel in their deliberations.
This systematic review found that current clinical practice guidelines on fall prevention and management for older adults showed a high degree of agreement in several areas in which strong recommendations were made, whereas other topic areas did not achieve this level of consensus or coverage. Future guidelines should address clinical applicability of their recommendations and include perspectives of patients and other stakeholders.
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