Falls in nursing home residents receiving pharmacotherapy for anemia

Figures & data

Table 1 All resident characteristics

	Vitamin B12 (n = 82)	Folic acid (n = 56)	Iron (n = 194)	DARB (n = 13)	EPO (n = 55)	No therapy (n = 348)	All residents (n = 632)
Demographics
Age, years (mean, SD)	82.1 (1.4)	77.3 (1.9)	82.7 (0.73)	74.2 (3.1)	81.7 (1.3)	80.3 (0.71)	81.0 (0.51)
Age category
<65 years	8%	17%	5%	15%	4%	12%	10%
65–74 years	8%	19%	13%	31%	15%	10%	11%
75–84 years	34%	29%	36%	31%	45%	34%	34%
85+ years	49%	35%	47%	23%	36%	44%	45%
Female	63%	55%	67%	46%	73%	73%	70%
African-American	10%	21%	11%	0%	18%	12%	12%
Mobility
ADL score (mean, SD)a	15.7 (0.86)	17.0 (1.1)	15.4 (0.61)	16.0 (1.7)	14.7 (1.0)	14.7 (0.45)	15.0 (0.34)
Balance score (mean, SD)a	2.6 (0.23)	3.2 (0.29)	3.0 (0.15)	2.8 (0.41)	2.8 (0.27)	2.7 (0.11)	2.8 (0.08)
Hemoglobin and renal function
Hemoglobin level (g/dL, mean, SD)	11.7 (0.18)	11.0 (0.25)	10.9 (0.12)	10.4 (0.41)	10.3 (0.22)	12.3 (0.09)	11.9 (0.07)
Hemoglobin level (g/dL)
13+ g/dL	20%	9%	8%	8%	4%	35%	26%
12 to <13 g/dL	30%	25%	20%	8%	5%	23%	23%
11 to <12 g/dL	18%	19%	18%	31%	18%	18%	19%
10 to <11 g/dL	12%	17%	26%	15%	24%	14%	17%
<10 g/dL	20%	29%	27%	38%	49%	9%	15%
Anemic (WHO definition)	61%	77%	78%	85%	93%	47%	57%
eGFR (MDRD) (mean, SD), mL/min/1.73 m^2,a	60.6 (3.4)	57.8 (4.4)	64.4 (2.1)	62.0 (10.0)	53.2 (3.1)	70.7 (1.8)	67.9 (1.3)
Low eGFR (MDRD), <60 mL/min/1.73 m^2	54%	57%	49%	62%	58%	41%	44%
Diseases and conditions
Chronic kidney diseaseb	21%	31%	14%	54%	27%	12%	14%
Congestive heart failure	40%	43%	37%	38%	38%	34%	35%
Coronary heart disease	23%	31%	24%	23%	24%	19%	21%
Diabetes (including insulin-dependent)	33%	43%	37%	54%	42%	29%	32%
Hypertension	77%	79%	71%	77%	80%	66%	69%
Hypotension	4%	7%	3%	0%	2%	1%	2%
Cerebral vascular disease	35%	38%	27%	15%	25%	30%	29%
Peripheral vascular disease	0%	2%	4%	0%	7%	6%	5%
Dementia	51%	64%	53%	38%	38%	54%	53%
Cancer	7%	14%	12%	8%	20%	7%	9%
Parkinson’s disease	12%	3%	8%	8%	5%	7%	7%
COPD	19%	21%	20%	15%	20%	23%	22%
Asthma	1%	5%	4%	0%	5%	5%	4%
Osteoarthritis	55%	38%	46%	54%	25%	40%	43%
Rheumatoid arthritis	4%	7%	6%	0%	7%	4%	4%
Neurological disease	15%	21%	16%	15%	11%	21%	20%
Current medications
Diuretic use	48%	45%	45%	62%	35%	44%	45%
Psychoactive medication use	77%	84%	64%	92%	73%	68%	68%
Beta blocker use	31%	36%	36%	15%	38%	24%	28%
Anemia therapy
Vitamin B12 (cyanocobalamin)	100%	51%	14%	23%	11%	0%	13%
Folic acid	30%	100%	11%	23%	20%	0%	8%
Iron	30%	39%	100%	31%	62%	0%	28%
DARB (darbepoetin alfa)	0%	1%	0%	100%	0%	0%	0%
EPO (epoetin alfa)	1%	2%	2%	0%	100%	0%	1%
No therapy	0%	0%	0%	0%	0%	100%	61%

Notes: Of the 632 people studied, many used more than one anemia therapy. All statistics above estimated using sampling weights.

a Some residents had missing values for eGFR, ADL Score, or Balance Score. For these, values were imputed from remaining characteristics to enable their inclusion in the regression models;

b where a diagnosis for chronic kidney disease was identified in the resident’s chart.

Abbreviations: ADL, activities of daily living; COPD, chronic obstructive pulmonary disease; DARB, darbepoetin; eGFR, estimated glomerular filtration rate; EPO, epoetin alfa; MDRD, Modification of Diet in Renal Disease; SD, standard deviation.

Table 2 All resident rates of falls and recurrent falls

Falling event	Hemoglobin level (g/dL)	Vitamin B12 (n = 82)	Folic acid (n = 56)	Iron (n = 194)	DARB (n = 13)	EPO (n = 55)	No therapy (n = 348)	All residentsa (n = 632)
Fell one or more times	All levels	33%	40%	27%	38%	18%	22%	24%
	13+	13%	0%	8%	100%	50%	13%	12%
	12 to <13	32%	55%	25%	0%	0%	23%	24%
	11 to <12	31%	25%	11%	25%	20%	30%	25%
	10 to <11	44%	70%	38%	0%	15%	27%	34%
	<10	51%	33%	33%	60%	19%	38%	35%
Fell repetitively (>1 fall)	All levels	18%	16%	14%	8%	2%	11%	12%
	13+	0%	0%	0%	0%	0%	6%	5%
	12 to <13	14%	9%	16%	0%	0%	11%	11%
	11 to <12	31%	24%	7%	0%	0%	9%	11%
	10 to <11	22%	28%	19%	0%	0%	18%	18%
	<10	28%	16%	16%	20%	4%	19%	18%

Notes:

a Of the 632 studied, many used more than one anemia therapy. All statistics above estimated using sampling weights.

Abbreviations: DARB, darbepoetin; EPO, epoetin alfa.

Table 3 Logistic regression model for falls

	Odds ratio	95% lower bound	95% upper bound	P value	95% Siga
Demographics
Age category
<65 years	Reference
65–74 years	1.48	0.46	4.77	0.511
75–84 years	2.64	0.89	7.85	0.081
85+ years	2.80	0.94	8.30	0.064
Female	1.02	0.63	1.67	0.927
African-American	1.30	0.71	2.36	0.392
Mobility
ADL score	0.97	0.95	1.00	0.094
Balance score	0.94	0.82	1.06	0.312
Labs: hemoglobin and renal function
Hemoglobin level
13+ g/dL	Reference
12 to <13 g/dL	2.18	1.11	4.27	0.024	*
11 to <12 g/dL	2.10	1.01	4.40	0.048	*
10 to <11 g/dL	3.58	1.67	7.69	0.001	*
<10 g/dL	3.54	1.45	8.65	0.006	*
Low eGFR (MDRD), <60 mL/min/1.73 m^2	1.04	0.67	1.62	0.872
Diseases and conditions
Chronic kidney disease	1.67	0.93	3.00	0.088
Congestive heart failure	0.98	0.63	1.52	0.920
Coronary heart disease	0.79	0.48	1.32	0.370
Diabetes (including insulin-dependent)	0.88	0.57	1.36	0.561
Hypertension	1.17	0.71	1.93	0.528
Hypotension	1.45	0.33	6.33	0.621
Cerebral vascular disease	0.84	0.53	1.33	0.455
Peripheral vascular disease	0.60	0.20	1.81	0.367
Dementia	1.03	0.66	1.60	0.900
Cancer	0.82	0.39	1.73	0.605
Parkinson’s disease	1.34	0.58	3.10	0.498
COPD	1.19	0.74	1.92	0.467
Asthma	1.03	0.32	3.29	0.966
Osteoarthritis	0.80	0.51	1.24	0.320
Rheumatoid arthritis	1.06	0.44	2.56	0.904
Neurological disease	1.03	0.57	1.84	0.927
Current medications
Diuretic use	1.25	0.78	1.99	0.351
Psychoactive medication useb	2.01	1.26	3.23	0.004	*
Beta blocker use	1.16	0.74	1.82	0.519
Anemia therapy
Vitamin B12 (cyanocobalamin)	1.24	0.68	2.24	0.485
Folic acid	1.81	0.86	3.78	0.117
Iron	0.83	0.51	1.33	0.434
DARB or EPO	0.46	0.21	1.01	0.052
Propensity to receive DARB or EPO	1.95	0.18	20.86	0.580

Notes: All model statistics above estimated using sampling weights.

a Asterisk indicates significant odds ratio at 95% confidence;

b Includes sedatives, hypnotics, antidepressants, antipsychotics.

Abbreviations: ADL, activities of daily living; COPD, chronic obstructive pulmonary disease; DARB, darbepoetin; eGFR, estimated glomerular filtration rate; EPO, epoetin alfa; MDRD, Modification of Diet in Renal Disease.

Table 4 Logistic regression model for recurrent falls

	Odds ratio	95% lower bound	95% upper bound	P value	95% Siga
Demographics
Age category
<65 years	Reference
65–74 years	5.62	0.46	68.81	0.176
75–84 years	14.84	1.31	168	0.030	*
85+ years	14.25	1.27	160	0.031	*
Female	0.61	0.32	1.16	0.128
African-American	1.02	0.47	2.20	0.959
Mobility
ADL score	0.99	0.95	1.03	0.656
Balance score	0.84	0.71	0.99	0.040	*
Labs: hemoglobin and renal function
Hemoglobin level
13+ g/dL	Reference
12 to <13 g/dL	2.84	1.03	7.82	0.043	*
11 to <12 g/dL	2.21	0.78	6.31	0.136
10 to <11 g/dL	4.74	1.65	13.58	0.004	*
<10 g/dL	3.36	1.03	11.01	0.045	*
Low eGFR (MDRD), <60 mL/min/1.73 m^2	1.14	0.64	2.03	0.645
Diseases and conditions
Chronic kidney disease	2.23	1.08	4.61	0.031	*
Congestive heart failure	0.66	0.36	1.19	0.162
Coronary heart disease	1.26	0.66	2.38	0.485
Diabetes (including insulin-dependent)	1.00	0.56	1.78	0.997
Hypertension	0.93	0.46	1.85	0.830
Hypotension	0.54	0.03	11.53	0.692
Cerebral vascular disease	0.66	0.35	1.28	0.219
Peripheral vascular disease	0.37	0.07	2.12	0.266
Dementia	0.55	0.28	1.07	0.077
Cancer	0.96	0.33	2.74	0.935
Parkinson’s disease	1.74	0.59	5.14	0.318
COPD	1.12	0.59	2.11	0.736
Asthma	1.50	0.38	5.93	0.561
Osteoarthritis	1.21	0.66	2.22	0.538
Rheumatoid arthritis	2.13	0.71	6.32	0.175
Neurological disease	1.12	0.50	2.53	0.783
Current medications
Diuretic use	1.18	0.63	2.22	0.607
Psychoactive medication useb	2.58	1.22	5.46	0.013	*
Beta blocker use	0.98	0.56	1.73	0.958
Anemia therapy
Vitamin B12 (cyanocobalamin)	1.19	0.55	2.57	0.664
Folic acid	1.32	0.53	3.28	0.548
Iron	0.80	0.43	1.49	0.486
DARB or EPO	0.06	0.01	0.30	0.001	*
Propensity to receive DARB or EPO	9.26	0.51	168	0.132

Notes: All model statistics above estimated using sampling weights.

a Asterisk indicates significant odds ratio at 95% confidence;

b Includes sedatives, hypnotics, antidepressants, antipsychotics.

Abbreviations: ADL, activities of daily living; COPD, chronic obstructive pulmonary disease; DARB, darbepoetin; eGFR, estimated glomerular filtration rate; EPO, epoetin alfa; MDRD, Modification of Diet in Renal Disease.

Table 5 Logistic regression model for falls and recurrent falls: subpopulation of residents with apparent chronic kidney disease

	Odds ratio	95% lower bound	95% upper bound	P value	95% Siga
Subpopulation with eGFR (MDRD) < 60 mL/min/1.73 m^2 or MDS Section I chronic kidney disease (checkbox or ICD-9 entry)
Falling
Vitamin B12	1.82	0.78	4.26	0.167
Folic acid	2.05	0.67	6.27	0.208
Iron	0.81	0.41	1.60	0.548
DARB or EPO	0.64	0.24	1.70	0.369
Recurrent falling
Vitamin B12	1.65	0.50	5.45	0.410
Folic acid	1.18	0.32	4.37	0.803
Iron	0.68	0.27	1.71	0.413
DARB or EPO	0.09	0.01	0.62	0.015	*

Notes: Findings from full adjusted models of these subpopulations show odds ratios for anemia therapies only. All model statistics above estimated using sampling weights.

a Asterisk indicates significant odds ratio at 95% confidence.

Abbreviations: DARB, darbepoetin; eGFR, estimated glomerular filtration rate; EPO, epoetin alfa; MDRD, Modification of Diet in Renal Disease; MDS, Minimum Data Set.