George is a 93-year-old male who lives with his son and daughter-in-law. Over the last six months, he has become frailer but continues to be reasonably independent. He is treated for hypertension, dyslipidemia, BPH, and has arthritis in his knees. He complained of feeling depressed when he moved in with his son after the death of his wife five years ago. He is taking perindopril, ASA, rosuvastatin, citalopram, tamsulosin and Vitamin D. He takes ibuprofen and half a zopiclone on an as needed basis. While out for a walk in the neighbourhood, he had a fall and his son has brought him in.
Issue: Could any of his medications be contributing to his falls?
Bottom Line: A number of medications have been implicated as being associated with falls. There is limited evidence confirming the falls risk associated with specific medications beyond a number of identified classes.
Evidence: Falls are a common occurrence with estimates of 30% of individuals aged 65 and over living in the community, and more than 50% of those living in residential care facilities having a fall annually. There are significant consequences to falls including recurrent pain, functional impairment, disability, and even death.[i] Risk factors for falls include postural hypotension, use of multiple medications (defined as greater than four), or impairments of cognition, vision, balance, gait or strength. The risk increases with age and as the number of factors increases.[ii]
Beyond focusing on numbers of medications, attempts have been made to characterize the risk of falls associated with particular classes of medications. The Beers Criteria specifically identify benzodiazepines and the Z drugs as being implicated with falls. Specifically, sedation and effects on alertness are a recognized side effect of these agents. For individuals with a history of falls, the Criteria also recommend not using certain anticonvulsants, antipsychotics, tricyclic and SSRI antidepressants, a number of anti-arrhythmics, glyburide and metoclopramide.[iii] This is based on an assessment of risk-benefit and the impact of a particular medication in the face of other risks an individual may have. It generally relates to the particular side effect profile of some of these medications. For example, enhancement of postural hypotension is a potential side effect of the tricyclics, and hypoglycemia is a potential side effect of glyburide. Metoclopramide has been associated with confusion. The antipsychotics have been implicated with prolonged QT syndromes and hypotension, etc.
Yet, the question remains as to which medications specifically have evidence around their role in contributing to the risk for falls. Woolcott et al published an update of previous meta-analyses that incorporated additional information and provided odds ratios for the risk of falling for a number of medication classes. In their study, benzodiazepines had an unadjusted odds ratio of 1.57 (95% CI 1.43 – 1.72); non-benzodiazepine sedative hypnotics had an unadjusted odds ratio of 1.47 (95% CI 1.35 – 1.62); neuroleptics and antipsychotics had an unadjusted odds ratio of 1.59 (95% CI 1.37 – 1.83); antidepressants had an unadjusted odds ratio of 1.68 (95% CI 1.47 – 1.91); antihypertensives had an unadjusted odds ratio of 1.24 (95% CI 1.01-1.50); and NSAIDs had an unadjusted odds ratio of 1.21 (95% CI 1.01 – 1.44)[iv]. These results were generally consistent with the results of previous meta-analyses. Woolcott took the analysis further, however. They looked at using additional analyses that adjusted for various factors and, with this, continued to demonstrate an increased likelihood of falling for the medication classes of sedatives and hypnotics; benzodiazepines; neuroleptics and antipsychotics; antidepressants; and NSAIDs. Diuretics and beta blockers were no longer found to be significantly associated with falls risk. Another study has demonstrated that cholinesterase inhibitors had an odds ratio of 1.53 (95% CI 1.02-2.30) because of an increased risk of syncope .[v][vi]
How then do we approach identification of individuals at risk for falls and determine whether or not any of their medications could be contributors? The American Geriatrics Society and British Geriatrics Society[vii] have jointly produced an updated clinical practice guideline for prevention of falls in older persons. It recommends screening for falls through asking three questions including: has the individual had two or more falls in the prior 12 months; are they presenting with an acute fall; and do they have difficulty with walking or balance. Positive responses to any of these three questions then precipitates assessment for known risk factors amongst which are use of multiple medications. The known medications of concern are as above. The only evidence to support reduction of specific medications, however, has been with looking at reduction in psychotropic medication as a single intervention.[viii] Adjustment and discontinuation of medications as part of a multifactorial intervention has also been shown to be effective in reducing falls.
George is on a number of medications that have the potential to increase his falls risk. With his frailty, his use of more than four medications, and his use of a number of medications that have the potential to affect his blood pressure, he has a number of risk factors in addition to the specific medications that may have an impact on falls risk. Consideration could be given to whether or not he continues to require the citalopram and the zopiclone.
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[i] Kannus P et al. Prevention of falls and consequent injuries in elderly people. Lancet 2005;366:1885-1893
[ii] Tinetti M et al. Effect of Dissemination of Evidence in Reducing Injuries from Falls. NEJM 2008;359(3):252-61
[iii] Beers Criteria 2012 Update JAGS – DOI: 10.1111/j.1532-5415.2012.03923.x
[iv] Woolcott J et al. Meta-analysis of the Impact of 9 Medication Classes on Falls in Elderly Persons. Arch Int Med 2009;169(21):1952-60
[v] Kim D et al. Dementia Medications and Risk of Falls, Syncope, and Related Adverse Events. JAGS 2011;59: 1019-31
[vi] Kwan E, Straus S. assessment and management of falls in older people. CMAJ 2014;186(16):E610-621
[vii] Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons. JAGS 2011;59(1): 148-157 (or online at: http://www.guideline.gov/content.aspx?id=37707)