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Medications are a prime factor contributing to falls, particularly in the elderly. Categories include antidepressants, anticonvulsants, antipsychotics, antihypertensives, opioids, sedative/hypnotics, benzodiazepines, and others. including some nonprescription medications.
A recent study showed an alarming increase in the prevalence of prescriptions for such medications in the 65 and older population (Shaver 2021). Their analysis used data on adults aged 65 years and older from the National Vital Statistics System (NVSS) and the medical expenditure panel survey (MEPS) for years 19992017. The study assessed prescription of medications considered fall risk increasing drugs (FRIDs), defined according to the CDC's Stopping Elderly Accidents, Deaths, and Injuries-Rx (STEADI-Rx) fall checklist.
The number of persons who received at least one prescription for a FRID increased from 57% in 1999 to 94% in 2017. Antihypertensives were far and away the most commonly prescribed drug category. But, the trend remained significant even after excluding antihypertensive drugs. The use of antidepressants increased dramatically in this population during this timeframe, from 7% to 16%, even as there was a slight decrease in tricyclic antidepressants (TCAs) from 4% in 1999 to 2% in 2017. The percentage of the population receiving an opioid reached a high in 2015 of 21% but began declining to a 2017 level of 16%. Prescribing of multiple FRID classes has increased as well.
Falls increased significantly across all demographics (sex, race, age category). Importantly, age-adjusted mortality due to falls increased from 29.40 per 100,000 in 1999 to 63.27 per 100,000 in 2017.
Notably, use of FRIDs was considerably higher among females. The authors stress this is relevant because female gender is an independent risk factor for falls and fractures. They note that this highlights the importance of additional patient risk factors for falls when considering making medication interventions.
Though antihypertensives were by far the most frequently prescribed category, there is likely considerable variation of fall risk between individual antihypertensives. For example, those more likely to cause orthostatic hypotension are probably more likely to increase the fall risk. But, the trends in the current analysis remained significant even after excluding antihypertensive drugs.
Perhaps the most striking finding was the increase in second-generation antidepressants such as selective-serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and various agents with novel mechanisms (ex. mirtazapine, trazodone, nefazodone, bupropion). Keep in mind that, though these drugs are in the antidepressant category, they are often prescribed for conditions other than depression, particularly certain types of pain.
The study highlights the importance of assessing individual fall risk factors in addition to the fall related risk of medications when prescribing, particularly in seniors. It would be a good idea to re-examine these risks when doing the recommended annual brown bag medication review. Undoubtedly, such review can lead to multiple opportunities for deprescribing (see our many columns potentially inappropriate medications in the elderly and on deprescribing listed below).
By the way, CDC's Stopping Elderly Accidents, Deaths, and Injuries-Rx (STEADI-Rx) Guide for Community Pharmacists is an excellent resource and set of tools, not just for pharmacists but for anyone dealing with medications and the older patient.
Some of our prior columns related to falls:
Some of our past columns on Beers List and Inappropriate Prescribing in the Elderly:
Some of our past columns on deprescribing:
Shaver AL, Clark CM, Hejna M, et al. Trends in fall‐related mortality and fall risk increasing drugs among older individuals in the United States,19992017. Pharmacoepidemiol Drug Saf. 2021; 1- 8
CDC (Centers for Disease Control and Prevention). STEADI-Rx.
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