Email UpdatesThe purpose of this artifact is to support identifying prescribed fall risk-increasing drugs (FRIDS) and incorporate Advancing Fall ASsessment and PreventIon PatIent-Centered Outcomes REsearch Findings intoDiverse Primary Care Practices (ASPIRE). FRIDS management guidance during primary care visits. The ASPIRE fall risk increasing drugs (FRIDS) management guidance will be accessed in the EHR in the context of existing primary care workflows. This will facilitate provider and patient review of risk factors and maintenance or management of pharmacological interventions that increase fall risk; provide talking points for patient education and engagement; and provide decision support for safely deprescribing FRIDS when indicate and agreed upon by the patient. The final FRIDS management care plan is saved as a note in the EHR and provided to the patients as a printout or in the after-visit summary, along with instructions and education materials when deprescribing FRIDS.
Artifact Creation and Usage
- Patricia Dykes
- Robert Lucero
- Nancy Latham
- Pam Neri
- Tien Thai
- Hannah Rice
- Denise Schentrup
- Ragnhildur I Bjarnadottir
- Kristen Shear
This CDS artifact and related data specifications are owned and stewarded by the Brigham and Women's Hospital (BWH), University of Florida Research Foundation, Inc (UF), and Regents of University of California (UC). BWH/UF/UC are not responsible for any use of the CDS artifact. BWH/UF/UC make no representations, warranties, or endorsement about the quality of any organization or physician that uses this CDS artifact.
This is a CQL-based CDS artifact and is executed by one of the components of the CDS Connect project (i.e. CDS-Connect-CQL-Services application). The CDS-Connect-CQL-Services application exposes this CQL_based CDS artifact thru a web-based API so it can be consumed by other applications.
Structured code that is interpretable by a computer (includes data elements, value sets, logic)
Provide CDS for select prioritized recommendations in the 2018 Interventions to Prevent Falls in Community-Dwelling Older Adults: US Preventive Services Task Force (USPSTF) Recommendation Statement. Among the USPSTF’s recommendations is to selectively offer multifactorial interventions to prevent falls, including initial assessment of medications. The National Institutes of Health National Institute on Aging places emphasis on medication management in addition to exercise for strength and balance, monitoring for environmental hazards, and regular medical care to ensure optimized hearing and vision. The American Geriatrics Society recommends the withdrawal or minimization of psychoactive or other medications. See Supporting Evidence for additional references used for the development of this artifact.
Primary care patients age 65+ who screen positive for fall risk (answer “yes” to one or more fall risk screening questions).
Older adults (age 65+ years) who fail their fall risk screening during a primary care, and have an active prescription of a fall risk increasing drug(s).
Not applicable
The US Preventive Service Task Force (USPSTF) acknowledges the role of medication management in recommending multifactorial interventions. The USPSTF finds that these interventions should be offered for selected patients depending on individual circumstances. (Level of Evidence – C)
- U.S. Preventive Services Task Force. Falls Prevention in Community-Dwelling Older Adults: Interventions. 2018; Available from: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/falls-prevention-in-older-adults-interventions1.
- National Institute on Aging. Prevent falls and fractures. 2017; Available from https://www.nia.nih.gov/health/prevent-falls-and-fractures.
- Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):148-157.
- Rice H, Garabedian PM, Shear K, Bjarnadottir RI, Burns Z, Latham NK, Schentrup D, Lucero RJ, Dykes PC. Clinical Decision Support for Fall Prevention: Defining End-User Needs. Appl Clin Inform. 2022;13(3):647-655.
Based on the evidence, this artifact recommends that PCPs consider medication management, or deprescribing FRIDS, for all patients age 65+ who are at risk for falls and have an active prescription of a fall risk increasing drug(s). In addition, this artifact recommends that PCPs consider consulting with a psychiatrist or neurologist for patients prescribed antipsychotics or antiepileptics.
The USPSTF recommends that clinicians selectively offer multifactorial interventions to prevent falls to community-dwelling adults 65 years or older who are at increased risk for falls, including medication management (Grade C).
Based on pooled analyses, the USPSTF reported on the quality of 19 fair and 7 good studies of multifactorial interventions that included 15,506 individuals. The following are studies that included deprescribing in the intervention:
- Salminen MJ, Vahlberg TJ, Salonoja MT, Aarnio PT, Kivelä SL. Effect of a risk-based multifactorial fall prevention program on the incidence of falls. J Am Geriatr Soc. 2009;57(4):612-619.
- Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med. 1994;331(13):821-827.
- Vind AB, Andersen HE, Pedersen KD, Jørgensen T, Schwarz P. An outpatient multifactorial falls prevention intervention does not reduce falls in high-risk elderly Danes. J Am Geriatr Soc. 2009;57(6):971-977.
Additionally, we including evidence from the following resources:
- de Vries M, Seppala LJ, Daams JG, van de Glind EMM, Masud T, van der Velde N; EUGMS Task and Finish Group on Fall-Risk-Increasing Drugs. Fall-Risk-Increasing Drugs: A Systematic Review and Meta-Analysis: I. Cardiovascular Drugs. J Am Med Dir Assoc. 2018 Apr;19(4):371.e1-371.e9. doi: 10.1016/j.jamda.2017.12.013. Epub 2018 Feb 12. PMID: 29396189.
- Seppala LJ, Wermelink AMAT, de Vries M, Ploegmakers KJ, van de Glind EMM, Daams JG, van der Velde N; EUGMS task and Finish group on fall-risk-increasing drugs. Fall-Risk-Increasing Drugs: A Systematic Review and Meta-Analysis: II. Psychotropics. J Am Med Dir Assoc. 2018 Apr;19(4):371.e11-371.e17. doi: 10.1016/j.jamda.2017.12.098. PMID: 29402652.
- Seppala LJ, van de Glind EMM, Daams JG, Ploegmakers KJ, de Vries M, Wermelink AMAT, van der Velde N; EUGMS Task and Finish Group on Fall-Risk-Increasing Drugs. Fall-Risk-Increasing Drugs: A Systematic Review and Meta-analysis: III. Others. J Am Med Dir Assoc. 2018 Apr;19(4):372.e1-372.e8. doi: 10.1016/j.jamda.2017.12.099. Epub 2018 Mar 2. PMID: 29402646.
Based on the evidence, this artifact recommends that PCPs consider medication management, or deprescribing FRIDS, for all patients age 65+ who are at risk for falls and have an active prescription of a fall risk increasing drug(s). In addition, this artifact recommends that PCPs consider consulting with a psychiatrist or neurologist for patients prescribed antipsychotics or antiepileptics.
The ASPIRE application recommends that PCPs consider medication management, or deprescribing FRIDS, for all patients age 65+ who are at risk for falls and have an active prescription of a fall risk increasing drug(s). Since FRIDS prescriptions may not be directly available in the host EHR due to interoperability limitations, we include the ability to capture this information in the ASPIRE user interface.
Provider opens an ambulatory wellness visit template.
Primary care patients age 65+ who screen positive for fall risk (answer “yes” to one or more fall risk screening questions), and have an active prescription of a fall risk increasing drug(s).
- Tailored fall risk increasing drug patient education handout(s)
- Tailored fall risk increasing drug deprescription regimen handout(s)
- Psychiatry or neurology specialty consult for deprescribing antipsychotic or antiepileptic medication
We pilot tested this logic in one rural (Florida) and one urban (Boston) primary care practice. We found that providers appreciated access to evidence-based recommendations and that patients are receptive to these recommendations. Upon completion of the clinic visit, the trained research staff member met with the patient in a private setting to ask a small set of open-ended questions and administer a patient-provider communication (Health Care Relationship Trust Scale) and shared decision-making questionnaire (Shared Decision-Making Questionnaire-9). For the HCR Trust Scale, patients from both sites reported a mean score of 58 (median 60, SD 6.1) out of a possible score range of 0-60. For the SDM-Q9 survey, patients from both sites reported a mean score of 92 (median 100, SD 14.9) out of a possible score range of 0-100. Once the 40 observations were completed, a focus group was conducted with clinicians at each site to gather individual perceptions of their experience using ASPIRE. At the end of both focus groups, the Health-ITUES survey was administered to each participating clinician in order to help gauge clinical feasibility and acceptability of the software in the primary care environment. Future refinements to ASPIRE will be considered based on these results.