Guideline for evaluating the effects of psychotropic drugs on motor vehicle driving performance in Japan: A tiered approach for the assessment of clinically meaningful driving impairment.

In December 2022, the Ministry of Health, Labour and Welfare (MHLW) of Japan issued and implemented the guideline for evaluating the effects of psychotropic drugs on motor vehicle driving performance. This guideline recommends the use of a tiered approach to assess clinically meaningful driving impairment. It is noted that adverse events cannot be solely explained by pharmacokinetics, as the onset and duration of these events vary. Among these adverse events, those affecting alertness, such as drowsiness caused by psychotropic drugs on driving performance, are more frequently observed during initial treatment stages and dose escalation. Hence, when evaluating the effects of psychotropic drugs on driving performance, it becomes crucial to assess the persistence of clinically meaningful impairment. Therefore, the MHLW guideline, developed by the authors, emphasizes the need to assess the temporal profile of adverse events affecting driving in all clinical trials. Additionally, the guideline states that when conducting driving studies, the timing of multiple dosing should consider not only the pharmacokinetics of the investigational drug but also its tolerance.

Review of Priapism Litigation in the United States.

OBJECTIVES: To review medical malpractice trends and to identify the most common claims filed against medical providers for the management of patients with priapism. METHODS: Using the Westlaw legal database, a search was done for the keyword "priapism" between July 1, 1980 and July 1, 2020. Cases were evaluated for plaintiff demographics, reasons for filing claims, management outcomes, legal verdicts and awards and further categorized based upon the timing of the alleged malpractice. RESULTS: Alleged negligence during the pre-management period was cited in 30 cases. Administration of psychotropic medications was the most common reasons for filing pre-management claims 22/56 (39.3%). Delay in care accounted for 18/56 (32.1%) and complications of surgery were 5/56 (8.9%) of claims. The majority of the completed cases were in favor of the defendants (39/47; 83.0%). There was no association between type of health care provider or timing of alleged malpractice and ultimate verdict. CONCLUSIONS: Prescribing psychoactive medications without warning of the adverse effect profile is the most common reason for claims filed against providers with trazodone as the leading medication. Medical providers should ensure that patients are well informed of this adverse effect prior to prescription. Regardless, the majority of medical malpractice cases carry a verdict in favor of the defendant.

Assessment of the abuse potential of methamnetamine in rodents: a behavioral pharmacology study.

RATIONALE: Methamnetamine (MNA; PAL-1046) is a new psychoactive substance that acts as a full biogenic amine transporter (BAT) substrate. BAT substrates promote neurotransmitter release from the nerve terminal and can be abused as stimulants. However, scientific information on the abuse potential of methamnetamine is lacking. OBJECTIVE: We evaluated the abuse liability of methamnetamine. METHODS: The effective dose range of methamnetamine was determined using a climbing behavior test. The rewarding effect and reinforcing effect of the test compound were evaluated in mice by conditioned place preference (CPP) testing and self-administration (SA) testing at the selected doses. Dopamine level changes were analyzed using synaptosomes and in vivo microdialysis to investigate the effects of methamnetamine on the central nervous system. Drug discrimination experiments were used to examine the potential similarity of the interoceptive effects of methamnetamine and cocaine. RESULTS: A significant response was observed in the climbing behavior test with 10 and 40 mg/kg intraperitoneally administered methamnetamine. In the CPP test, mice intraperitoneally administered methamnetamine (10 and 20 mg/kg) showed a significant preference for the drug-paired compartment. In the SA test, mice that intravenously received 1 mg/kg/infusion showed significant active-lever responses. Dopamine was significantly increased in synaptosomes and in in vivo microdialysis tests. Furthermore, methamnetamine showed cross-generalization with cocaine in a dose-dependent manner. CONCLUSIONS: Methamnetamine exhibits interceptive stimulus properties similar to those of cocaine and induces rewarding and reinforcing effects, suggesting its dependence liability potential.

Lifetime prevalence of novel psychoactive substances use among adults in the USA: Sociodemographic, mental health and illicit drug use correlates. Evidence from a population-based survey 2007-2014.

INTRODUCTION: As Novel psychoactive substances (NPS) are conceived to mimic the effects of common illicit drugs, they represent a serious public health challenge due to the spike in intoxications and fatalities that have been linked to their use. This study aims to provide epidemiological data on NPS use in the USA, determining lifetime prevalence of use and defining demographic, socioeconomic, drug use patterns and mental health correlates. METHODS: This study uses secondary data from the US National Survey on Drug Use and Health (NSDUH), which is a large cross-sectional population-based survey carried out annually in the USA. We analysed data from 2007-14 (N = 307,935) using bivariate descriptive analysis and binary logistic regression to calculate prevalence and determine factors underlying NPS consumption. Adjusted odds ratios (OR) with 95% CI's were calculated for a set of selected independent variables. RESULTS AND DISCUSSION: Our analysis NSDUH from 2007-14 highlights an increase in NPS use among adults, especially among white young men aged 18 to 25. Although the level of education of NPS users was relatively higher as compared to non-users, NPS users seemed to have a less wealthy situation. However, socioeconomic vulnerability appeared to be less important than mental health issues as a correlate to NPS use. NPS users seem to have followed a pattern of polysubstance use throughout their life, which involves both traditional illicit drugs and classic synthetic drugs. As NPS use seemed to be more prevalent among people having mental health issues, the rise in their use may have a negative impact on population mental health outcomes. CONCLUSION: Further comparative research on trends in NPS use and potential public health responses would be instrumental for developing appropriate health interventions, including drug checking, education for users and training for healthcare professionals working both within emergency wards and in/outpatient addiction and mental health services.

Medication Use and Health Care Utilization After a Cost-sharing Increase in Schizophrenia: A Nationwide Analysis.

BACKGROUND: Increases in prescription drug cost-sharing may decrease adherence to treatment among persons with schizophrenia and lead to discontinuation of use and an increased risk of hospitalization. OBJECTIVE: The objective of this study was to investigate the impact of new deductible and increased drug copayments implemented on antipsychotic and other drug purchases and on rates of hospitalizations and primary care contacts among persons with schizophrenia in Finland. RESEARCH DESIGN: Interrupted time series analysis. SUBJECTS: All persons with schizophrenia in Finland who were alive at the beginning of 2015 (N=41,017). MEASURES: We measured the rates of antipsychotic, other psychotropic and cardiometabolic drug purchasers, hospitalizations, and primary care contacts during 2015 and 2016 with data collected from several nationwide health care registers. RESULTS: During 2016, the proportion of antipsychotic purchasers decreased by -0.26 percentage points per month [95% confidence interval (CI): -0.47 to -0.05] compared with 2015. The trend of other psychotropic purchasers decreased to -0.13 percentage points per month in 2016 (95% CI: -0.22 to -0.04) compared with 2015 and cardiometabolic drug purchases to -0.17 percentage points per month (95% CI: -0.29 to -0.05) compared with 2015. The decreasing trend of psychiatric hospitalizations in 2015 halted in 2016. There were no other significant differences in health care utilization. CONCLUSIONS: In our nationwide time-series analysis, we observed decreases in the slopes of antipsychotic and other drug purchases of persons with schizophrenia after prescription drug cost-sharing increase implementation on January 1, 2016. Policymakers need to be aware of the unintended consequences of increasing cost-sharing among people with severe mental disorders.

Interventions to improve medication adherence in mental health: the update of a systematic review of cost-effectiveness.

OBJECTIVE: Medication non-adherence in mental health problems has social and economic costs. The objective of the study was to review the cost-effectiveness of interventions to enhance medication adherence in patients with mental health problems. METHODS: The update of a previous systematic review was performed. Databases were searched in June 2019: MEDLINE, PSYCINFO, EMBASE, CINAHL, CRD, WOS. Cost-effectiveness studies comparing an intervention to improve the medication adherence with other interventions/usual care in adults with mental health problems were included. Data were extracted, methodological quality of the studies was assessed and a narrative synthesis was performed. RESULTS: Nine studies were included in the review. The interventions that showed medication adherence increase were: a financial incentive when depot injection was taken by patients with psychotic disorders, a value-based benefit design policy including copayment and counselling in a company setting, and a medication treatment decision supported by a pharmacogenetic test. The other studies (coaching by pharmacists; a psychological and educational intervention at health care centres) did not find differences between groups. No study found cost differences between alternatives. CONCLUSIONS: Interventions to improve medication adherence in adults with mental health problems could be cost-effective, especially those based on financial incentives, although more research is needed. KEYPOINTS There are several types of interventions designed to enhance medication adherence in patients with mental health problems. Few of them have demonstrated cost-effectiveness. Two studies found that a financial incentive per depot injection in patients with psychotic disorders improved the medication adherence. Two other studies found improvement in adherence due to two specific interventions: a value-based benefit design policy in a company setting and a pharmacogenetic test supporting the medication treatment decision. No study found differences in costs between the intervention and the comparator. More research is needed to implement cost-effective interventions.

Effects of macroeconomic fluctuations on mental health and psychotropic medicine consumption.

Our aim in this paper is to understand the impact of macroeconomic fluctuations on mental health and psychotropic medicine consumption. In order to do that we exploit differences in the fluctuations of business cycle conditions across regional units in Catalonia. Our findings suggest that, in general, economic fluctuations at the local level had no significant effect on the consumption of psychotropic medicines. However, we show that a deterioration in local labour market conditions is associated with a reduction in the consumption of anxiolytics medicines. We also report an increase in the consumption of anxiolytics in regions with a softer deterioration in the economic situation. Although we report mild improvements in both mental and physical health for some sub-groups of the population, we also find significant reductions on the probability of sleeping 6 h or more. Thus, these elements point towards potential negative effects of local labour market conditions on health in the medium/long term.

Therapeutic drug monitoring (TDM) during maintenance phase treatment at a community mental health centre.

OBJECTIVE: To assess the extent to which therapeutic drug monitoring during maintenance phase treatment with lithium and clozapine was performed according to an agreed protocol and to identify strategies that may support monitoring. METHODS: Data concerning the prescribing and monitoring patterns of lithium for 31 patients and clozapine for 53 patients were collected retrospectively over a period of 2 years. RESULTS: Adherence to clozapine monitoring throughout the study period was 90.5%, while the monitoring of lithium was less likely at 58.1% (P < 0.001). While those prescribed lithium were less likely to adhere to prescribed dosing than those prescribed clozapine (P < 0.007), they were also more likely to have a change of medication (P < 0.005) and require admission to inpatient care (P < 0.002). CONCLUSIONS: Despite the initiatives established to improve adherence to monitoring, there was a significantly lower level of lithium monitoring compared to that of clozapine. Strategies that are likely to support monitoring include the use of labels to clarify tests required, the use of a database to keep track of those requiring pathology tests and allocation of time each week for a nurse to work with medical staff and case managers to support monitoring.

Changes in Prescription of Psychotropic Drugs After Introduction of Polypharmacy Reduction Policy in Japan Based on a Large-Scale Claims Database.

BACKGROUND AND OBJECTIVES: In Japan, polypharmacy reduction policy, which reduces the reimbursement of medical cost, was introduced to address unnecessary psychotropic polypharmacy. The rule was applied to the prescriptions of three or more anxiolytics or three or more hypnotics in the policy introduced in 2012. The prescriptions of four or more antidepressants or four or more antipsychotics were added to the rule in the policy revised in 2014. Furthermore, the prescriptions of three or more drugs of anxiolytics, hypnotics, antidepressants, or antipsychotics were subject to the reduction criteria of the policy revision in 2016. Benzodiazepine receptor agonists (BZs) are classified both into anxiolytics and hypnotics, and the reduction rule was not applied to the category of BZs before April 2018. This study aimed to examine the effect of the policy on the prescriptions of four drug categories as well as BZs from the point of view of the number of drugs and doses. METHODS: This was a retrospective observational study using a large-scale Japanese health insurance claims database. Patients who were prescribed at least one psychotropic drug (anxiolytic, hypnotic, antidepressant, or antipsychotic) during the study period (from April 2011 to March 2017) were selected. Segmented regression analysis was used to analyze the proportions of patients with three or more or four or more drugs as well as patients above clinically recommended doses, and the means of the average daily doses by drug category. RESULTS: A total of 312,167 patients were identified as a study population. The proportions of patients with three or more drugs in anxiolytics, hypnotics, antidepressants, and antipsychotics significantly decreased after the introduction or revisions of the policy, but not BZs. The proportions of patients with three or more drugs in March 2017 were 0.9%, 2.0%, 1.2%, 2.4%, and 8.9% in anxiolytics, hypnotics, antidepressants, antipsychotics, and BZs, respectively. The effect of the policy in reducing the proportions of patients above clinically recommended doses was identified in antipsychotics after the revision in 2016, but not identified in the sum of anxiolytics and hypnotics as well as BZs after the revision in 2014, and antidepressants after the revision in 2016. The proportions of monotherapy were increased from April 2011 to March 2017 only for antidepressants (76.9% → 80.8%) and antipsychotics (79.8% → 82.1%), and not changed or decreased for anxiolytics (85.2% → 85.7%), hypnotics (78.6% → 77.6%), sum of anxiolytics and hypnotics (68.1% → 65.7%), BZs (68.0% → 67.3%), and sum of psychotropic drugs (52.1% → 49.9%). CONCLUSIONS: The polypharmacy reduction policy reduced the proportions of patients with three or more drugs in four drug categories, but not BZs. Only limited effects were seen for reducing the proportions of patients above clinically recommended doses. The policy was revised in April 2018 again. Further investigation is needed to examine the effect of the revision in 2018.

Improvement of impulse control disorders associated with levodopa-carbidopa intestinal gel treatment in advanced Parkinson's disease.

Impulse control behaviors are a frequent comorbidity for patients with Parkinson's disease (PD). The objective of the present study was to evaluate the effectiveness levodopa-carbidopa intestinal gel (LCIG) therapy on impulse control disorders (ICDs) in patients with advanced PD. We conducted a multicenter, observational, and prospective (6 months follow-up) study that included consecutive PD patients assigned to LCIG through routine medical practice. Patients completed visits at baseline, 1, 3, and 6 months after percutaneous endoscopic gastrostomy procedure. The following outcomes were evaluated: presence and severity of ICDs and other neuropsychiatric disorders, sleep disturbances, patients' quality of life, and caregivers' burden. Sixty-two patients were included at baseline: mean age 72.2 years (SD ± 7.0), 42% women. Median duration of PD symptoms was 13.5 years (IQR 5.5-21.5) and median time with motor fluctuations was 5.0 years (IQR 1.0-9.0). Treatment with LCIG infusion was associated with progressive and significant improvements in ICDs symptoms over the study period (64.4% reduction in the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's disease-Rating Scale score). Psychotic and other neuropsychiatric symptoms were also significantly reduced, and patients' sleep quality and psychosocial function improved. Caregivers' burden remained unchanged. There was a significant improvement in the daily "Off" time [7.4 h (SD ± 4.0) vs 1.5 h (SD ± 1.8); p < 0.0001] at the end of follow-up, whereas duration of dyskinesias was not affected. ICDs significantly improved after 6-month LCIG treatment in a group of PD patients with mild-to-moderate neuropsychiatric disturbances.

Polydrug epidemiology: Benzodiazepine prescribing and the drug overdose epidemic in the United States.

BACKGROUND: Although polydrug incidents comprise a substantial proportion of overdose deaths, scholarly and popular focus has centered on prescription opiates. This study examines the role of benzodiazepine and opioid prescriptions on overdose-both individually and synergistically-using data from Medicare Part D, a source of prescription drug claims for about 35 million Americans. METHODS: Prescribing data from the Medicare Part D Public Use Files for 2013, 2014, and 2015 (approximately 3.5 billion prescription drug claims) are geolocated using the prescriber's national provider identifier to calculate the proportion of claims for opioids and benzodiazepines in each county. These rates are matched with overdose data and controls to compile an analytic dataset of 9105 county-years. Multinomial logistic regression is used to estimate the probability that a county experiences higher rates of overdose fatalities. RESULTS: A 1% increase in the benzodiazepine proportion of claims is associated with 1.2 odds of high, versus low, overdose (P < .1) and 1.4 odds of very high overdose (P < .05). Moreover, there was a substantial interaction between opioids and benzodiazepines (P < .001). A county with 6% benzodiazepine prescriptions and 12% opioid prescriptions has a .58 predicted probability of very high overdose, significantly higher (P < .001) than the .33 probability for a county with 12% opioid prescriptions but 3% benzodiazepine prescriptions. CONCLUSION: These findings shed light on the polydrug epidemiology of the overdose epidemic. Overdose deaths are highest where elevated opioid and benzodiazepine claims coexist. Overdose levels may reflect polydrug use and misuse, requiring clinical and policy responses beyond reducing opioid prescriptions.

Actual Versus Expected Doses of Half Tablets Containing Prescribed Psychoactive Substances: A Systematic Review.

OBJECTIVE: To assess through a systematic review of the literature if the practice of splitting tablets containing psychoactive/psychotropic medications for medical or economic reasons would result in the expected doses. DATA SOURCES: A MEDLINE and PsycInfo comprehensive search of English-language publications from January 1999 to December 2015 was conducted using the terms describing tablet splitting (tablet splitting, split tablets, tablet subdivision, divided tablets, and half tablets) and psychoactive substances (psychoactive medicines, psychotropic medicines, antidepressants, anxiolytics, anticonvulsants, antipsychotics, and antiparkinsonian agents). An additional supplementary search included the references from the articles found. STUDY SELECTION/DATA EXTRACTION: Studies were included if splitting content was directly related to psychoactive medications and examined the effect of tablet splitting on drug uniformity, weight uniformity, and adherence of psychoactive drugs. Articles were systematically reviewed and examined regarding the study design, methodology, and results of the study. A total of 125 articles were screened, and 13 were selected. RESULTS: Tablet splitting implications are extensive, yet substantial deviations from the ideal weight, potency, and dose uniformity are more prone to be important to patient safety. The uneven division of tablets might result in the administration of different doses than what was prescribed, causing under- or overdosing, which might be relevant depending on the drug. In 55% of the cases, splitting psychoactive drugs was satisfactory. CONCLUSIONS: It cannot be generalized that splitting psychoactive drugs compromises dose accuracy, thus tablet splitting might still be employed in cases in which the advantages outweigh the disadvantages. It is recommended that alternatives be adopted to prevent the disadvantages related to tablet splitting.

Medicinal foods and beverages among Maasai agro-pastoralists in northern Tanzania.

ETHNOPHARMACOLOGICAL RELEVANCE: Pastoralist Maasai populations of east Africa use several different wild plants as dietary and medicinal additives in beverages (soups and teas), yet little is known about how the plants used and the rationales for use compare and contrast across different Maasai beverages, including how gender specific dietary and health concerns structure patterns of intake. AIM OF THE STUDY: We investigated three Maasai beverages: almajani (tea or herbal infusion); motorí (traditional soup); and okiti (psychoactive herbal tea). In order to build knowledge about the cultural functions of these Maasai food-medicines and their incidence of use we also investigated use rationales and self-reported frequencies of use. We conclude by examining gender differences and the possible pharmacological antimicrobial activity of the most frequently used plants. MATERIALS AND METHODS: Research was conducted in 2015, with a population of semi-nomadic agropastoralist Maasai residing in northern Tanzania. Data were collected using key informant interviews, plant collections, n = 32 structured surveys, and n = 40 freelist interviews followed by a literature review to determine the known antimicrobial activity of the most used plants. RESULTS: We identified 20 plants that Maasai add to soup, 11 in tea, and 11 in the psychoactive tea, for a total of 24 herbal additives. Seven plant species were used in all three Maasai beverages, and these clustered with 10 common ailments. Based on self-reports, women use the beverages less frequently and in smaller amounts than men. There were also several gender differences in the plants that Maasai add to motorí and their associated use rationales. CONCLUSIONS: There are several intersections concerning the plant species used and their associated rationales for use in almajani, motori, and okiti. Moving outward, Maasai beverages and their additives increasingly involve gender specific concerns. Female use of food-medicines, relative to men, is structured by concerns over pregnancy, birth, and lactation. The frequent consumption of herbal additives, many of which contain antimicrobial compounds, potentially helps modulate infections, but could have other unintentional effects as well.

Drug-related problems and changes in drug utilization after medication reviews in nursing homes in Oslo, Norway.

OBJECTIVE: We describe the drug-related problems (DRPs) identified during medication reviews (MRs) and the changes in drug utilization after MRs at nursing homes in Oslo, Norway. We explored predictors for the observed changes. DESIGN: Observational before-after study. SETTING: Forty-one nursing homes. INTERVENTION: MRs performed by multidisciplinary teams during November 2011 to February 2014. SUBJECTS: In all, 2465 long-term care patients. MAIN OUTCOME MEASURES: DRPs identified by explicit criteria (STOPP/START and NORGEP) and drug-drug interaction database; interventions to resolve DRPs; drug use changes after MR. RESULTS: A total of 6158 DRPs were identified, an average of 2.6 DRPs/patient, 2.0 for regular and 0.6 for pro re nata (prn) drugs. Of these patients, 17.3% had no DRPs. The remaining 82.7% of the patients had on average 3.0 DRPs/patient. Use of unnecessary drugs (43.5%), excess dosing (12.5%) and lack of monitoring of the drug use (11%) were the most frequent DRPs. Opioids and psychotropic drugs were involved in 34.4% of all DRPs. The mean number of drugs decreased after the MR from 6.8 to 6.3 for regular drugs and from 3.0 to 2.6 for prn drugs. Patients with DRPs experienced a decrease of 1.1 drugs after MR (0.5 for regular and 0.6 for prn drugs). The reduction was most pronounced for the regular use of antipsychotics, antidepressants, hypnotics/sedatives, diuretics, antithrombotic agents, antacid drugs; and for prn use of anxiolytics, opioids, hypnotics/sedatives, metoclopramide and NSAIDs. CONCLUSION: The medication review resulted in less drug use, especially opioids and psychotropic drugs.

Interventions to Improve Medicines Management for People with Dementia: A Systematic Review.

BACKGROUND: The importance of optimising medicines management for people with dementia has been emphasised through research and policy. However, evidence is currently lacking regarding how to achieve this in this patient population. OBJECTIVE: The aim was to assess the effectiveness of medicines management interventions for people with dementia living in their own home or a care home, with or without nursing care. METHODS: A systematic literature search was conducted in February 2016 across six electronic databases and three trial registries. Inclusion criteria were randomised controlled trials of medicines management (prescribing, dispensing, adherence, and/or review) interventions for people with dementia living in their own homes or care homes, with or without nursing. An assessment of quality was conducted for all studies, using the Cochrane tool for assessing the risk of bias. All outcomes were considered using a narrative approach. RESULTS: Overall, 1365 articles were identified, with three studies eligible for inclusion (n = 475 participants). The studies were heterogeneous both in terms of intervention components, setting, and outcomes used. Aspects of medicines management targeted included medication review, adherence, and administration. Improvements in psychotropic prescribing were observed; however, the interventions had limited effects on other outcomes such as wellbeing, falls and dementia severity. CONCLUSION: This review highlights the limited number of studies examining medicines management interventions for people with dementia. Of the work that has been conducted to date, emphasis has been placed on psychotropic drug use. Future research must target community-dwelling dementia patients and take a holistic approach to medicines management.

Prevalence of mind and body exercises (MBE) in relation to demographics, self-rated health, and purchases of prescribed psychotropic drugs and analgesics.

This study aims to identify any differences regarding gender, age, socioeconomic status (SES), self-rated health, perceived stress and the purchase of prescribed drugs among people who practice mind and body exercises (MBE) extensively compared to people who do not. METHODS: The study includes 3,913 men and 4,803 women aged 20-72 who participated in the Swedish Longitudinal Occupational Survey of Health (SLOSH). The respondents were divided into three groups depending on frequency of MBE practice (never/seldom/often). Measures regarding MBE practice, health behaviors, self-rated health, and illnesses were drawn from the SLOSH questionnaire, while more objective measures of socioeconomic status and education were derived from registry data. In addition, data on purchases of prescription drugs for all respondents were included in the study. These data were obtained from the Swedish Prescribed Drug Register, which contains information about prescription drugs dispensed at Swedish pharmacies. Separate analyses were performed for mental MBE (mindfulness, meditation, relaxation techniques) and physical MBE (yoga, Tai Chi, Qi Gong), respectively. RESULTS: A high intensity MBE practice is cross-sectionally related to poor self-assessed health (sleeping problems, pain, depressive symptoms, mental disorders), high levels of stress, and high levels of purchases of psychotropic drugs and analgesics. These cross-sectional relationships are generally stronger for mental MBE than for bodily-directed MBE. More women than men are practicing MBE on a regular basis, and physically active people participate to a greater extent in MBE compared with the physically inactive. CONCLUSION: Overall, the study shows that frequent participation in mind and body exercises is associated with high levels of purchases of psychotropic drugs and analgesics as well as with poor self-assessed health and high levels of stress. However, since this is a cross-sectional study, it is impossible to establish cause and effect, and to further investigate the associations found; longitudinal studies that can account for temporality between covariates and MBE use are needed.

The consumption of two or more fall risk-increasing drugs rather than polypharmacy is associated with falls.

AIM: The presemt study aimed to determine the association between the risk of recurrent and injurious falls with polypharmacy, fall risk-increasing drugs (FRID) and FRID count among community-dwelling older adults. METHODS: Participants (n = 202) were aged ≥65 years with two or more falls or one injurious fall in the past year, whereas controls (n = 156) included volunteers aged ≥65 years with no falls in the past year. A detailed medication history was obtained alongside demographic data. Polypharmacy was defined as "regular use of five or more prescription drugs." FRID were identified as cardiovascular agents, central nervous system drugs, analgesics and endocrine drugs; multiple FRID were defined as two or more FRID. Multiple logistic regression analyses were used to adjust for confounders. RESULTS: The use of non-steroidal anti-inflammatory drugs was independently associated with an increased risk of falls. Univariate analyses showed both polypharmacy (OR 2.23, 95% CI 1.39-3.56; P = 0.001) and the use of two or more FRID (OR 2.9, 95% CI 1.9-4.5; P = 0.0001) were significantly more likely amongst fallers. After adjustment for age, sex and comorbidities, blood pressure, and physical performance scores, polypharmacy was no longer associated with falls (OR 1.6, 95% CI 0.9-2.9; P = 0.102), whereas the consumption of two or more FRID remained a significant predictor for falls (OR 2.8, 95% CI 1.4-5.3; P = 0.001). CONCLUSIONS: Among high risk fallers, the use of two or more FRID was an independent risk factor for falls instead of polypharmacy. Our findings will inform clinical practice in terms of medication reviews among older adults at higher risk of falls. Future intervention studies will seek to confirm whether avoidance or withdrawal of multiple FRID reduces the risk of future falls. Geriatr Gerontol Int 2017; 17: 463-470.