Student Forum Medication-Related Falls in the Elderly: Mechanisms and Prevention Strategies Kristin L. Glab, Fae Gwen G. Wooding, Kristin A. Tuiskula Accidental falls represent a major public health concern for the elderly population. The use of psychotropic medications, cardiovascular medications, and nonsteroidal anti-inflammatory drugs is associated with an increased risk of falling. The mechanisms by which these medications increase fall risk are not fully understood but may include orthostatic hypotension, sedation, sleep disturbance, confusion, dizziness, and other central nervous system problems. A better understanding of these mechanisms may help guide pharmacists’ interventions in reducing falls by educating patients, monitoring symptoms, adjusting doses, or discontinuing drugs implicated in falls. This article provides a discussion of the mechanisms by which certain classes of medications may contribute to falls and pharmacotherapeutic recommendations for preventing them. Key Words: Antidepressant, Antihypertensive agents, Antipsychotic, Cardiovascular, Drug toxicity, Falls, Geriatrics, Nonsteroidal anti-inflammatory drugs, Polypharmacy, Psychotropic drugs. abbreviations: ACEI = Angiotensin-converting enzyme inhibitor, AE = Adverse effect, A fib = Atrial fibrillation, ARB = Angiotensin-receptor blocker, BP= Blood pressure, CNS = Central nervous system, CV = Cardiovascular, NSAID = Nonsteroidal anti-inflammatory drug, SSRI = Selective serotonin-reuptake inhibitor, TCA = Tricyclic antidepressant. Consult Pharm 2014;29:413-17.
Introduction Falls are a leading cause of injury and injury-related death among the elderly population.1 The causes of falls are generally multifactorial; significant risk factors include dementia, neuromuscular disorders, muscle weakness, vision and hearing problems, environmental hazards, and polypharmacy.1 Several classes of medications, including psychotropic medications, cardiovascular (CV) medications, and nonsteroidal anti-inflammatory drugs (NSAIDs), have been associated with an increased risk of falls (Table 1).2,3 An understanding of how these medications contribute to fall risk should help guide fall-reduction programs and medication reviews for elderly patients. This article will review the medications commonly associated with falls in the elderly population, discuss possible mechanisms, and provide recommendations for preventing falls.
Psychotropic Medications Psychotropic medications include several drug classes commonly associated with falls: sedative-hypnotics, antidepressants, and antipsychotics.1 The use of a single psychotropic medication increases elderly patients’ fall risk by 30% to 80%, and the use of multiple psychotropic medications further increases fall risk.2-4 The anticholinergic and sedative properties of psychotropic agents are believed to be responsible for this increased risk.1 Anticholinergic adverse effects (AEs) associated with these medications include sedation, confusion, difficulty concentrating, hallucinations, delirium, and agitation. Hypnotic agents, including benzodiazepines, nonbenzodiazepine sedative-hypnotics, first-generation antihistamines, and barbiturates, may directly increase the risk of falling as a result of postural instability, prolonged sedation, and decreased psychomotor performance and cognitive function.4 Elderly patients taking these agents should be monitored for AEs and be educated on sleep hygiene to reduce the need for hypnotic agents. Optimizing the dose and dosing schedule of medications that contribute to insomnia can also help to minimize the use of hypnotic agents. Nonbenzodiazepine hypnotics, including zolpidem, zaleplon, and zopiclone, should
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Student Forum Table 1. Medications Associated with Falls Drug Class
Examples
Antidepressants
Amitriptyline, Bupropion, Citalopram, Fluoxetine, Mirtzapine, Nortriptyline, Paroxetine, Selegiline, Sertraline, Trazodone, Venlafaxine
Antipsychotics
Aripiprazole, Chlorpromazine, Haloperidol, Olanzapine, Quetiapine, Risperidone
Benzodiazepines
Alprazolam, Chlordiazepoxide, Clonazepam, Diazepam, Lorazepam
Cardiovascular Agents
Digoxin, Disopyramide, Procainamide, Quinidine
Diuretics
Acetazolamide, Bumetanide, Furosemide, Hydrochlorothiazide, Spironolactone, Triamterene
NSAIDs
Indomethacin, Ketorolac
Sedatives and Hypnotics
Chloral Hydrate, Hydroxyzine, Phenobarbital, Promethazine, Zaleplon, Zolpidem
Abbreviation: NSAIDs = Nonsteroidal anti-inflammatory drugs. Source: References 1-3, 8.
generally be recommended before benzodiazepines and agents with greater anticholinergic and sedation potential.4 Ramelteon may also be a safer option for elderly patients who have increased sleep onset latency.5 Nonetheless, the long-term use of any hypnotic agent should be avoided whenever possible.1 Both depression and the use of antidepressants are associated with an increased risk of falls.6 The risk is highest for patients who have recently initiated antidepressant therapy, before the drug has been able to improve the patient’s symptoms of depression. Additionally, fall risk appears to be dose-dependent, and for this reason, it is generally recommended that elderly patients start on a low dose of antidepressant and gradually increase the dose as tolerated.6 Tricyclic antidepressants (TCAs), tetracyclics, and trazodone are known to cause sedation, sleep disturbance with daytime drowsiness, and orthostatic hypotension via their effects on histamine receptors and α-adrenoreceptors.6 Selective serotonin-reuptake inhibitor (SSRI) use is associated with an increase in fall risk comparable to that of TCA use, but the mechanism by which SSRIs increase this risk is uncertain. SSRIs can cause sedation and orthostatic hypotension, but these side effects are
414
generally less common and less severe than those observed in patients taking TCAs. Instead, it may be that SSRIs increase the risk of falling through their central nervous system (CNS)-alerting effects such as sleep disturbance, insomnia, and nocturia.6 When these AEs lead to nighttime ambulation or daytime drowsiness, elderly patients may be at increased risk of falling. Sleep disturbance is an AE common to most antidepressant medications (as well as to depression itself), which may explain the increase in fall risk. In lieu of evidence that any particular antidepressant class is associated with a reduced risk of falling, the choice of antidepressant should be made based on side effect profiles and the potential for drug-drug interactions. Sedation and sleep disturbance may also play a role in the increased risk of falls associated with antipsychotic agents. Although typical antipsychotics have a greater incidence of extrapyramidal side effects (e.g., akathisia, pseudoparkinsonism, and dystonic reactions) when compared with atypical antipsychotics, studies have found that both classes of antipsychotic medications increase fall risk to a comparable degree.1,7 This observation may be explained by the serotonergic and histaminergic receptorblocking properties of atypical antipsychotics, which may
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Medication-Related Falls in the Elderly: Prevention Strategies
increase fall risk via sedation and orthostatic hypotension. Whereas CNS effects may directly increase the risk of falling, AEs that heighten the severity of fall-related injuries increase the likelihood that a fall will be recalled and reported, thereby increasing the apparent fall risk. For example, the long-term use of antipsychotics may increase the risk of fracture by inducing hyperprolactinemia and a reduction in bone-mineral density.7 Because of their AEs and the potential to increase the risk of falling and cerebrovascular accidents, antipsychotics should be reserved for elderly patients with a history of schizophrenia or schizoaffective disorder, and their use for off-label indications should be avoided unless therapeutic alternatives are unavailable.7,8 When it is necessary to treat a patient at risk of falling with an antipsychotic agent, side effect profiles can help guide drug selection (Table 2).
Cardiovascular Medications Antihypertensive agents may increase the risk of falling by causing postural, orthostatic, or postprandial hypotension; dizziness; syncope; or other CNS side effects (as in the case of centrally acting agents such as clonidine), especially while initiating or titrating antihypertensive therapy.10,11 The elderly, in particular, are at increased risk as a result of age-related physiological changes that influence blood pressure (BP) regulation and exacerbate these side effects.1,11 For patients 80 years of age or older, systolic BP of 140-145 mmHg is a reasonable BP goal if tolerated, but systolic BP goals of 130 and diastolic BP < 65 mmHg should be avoided because of concerns that vital organ perfusion may be reduced.12 Diuretics are the class of antihypertensive medications most consistently associated with falls.2-3,10 Recent studies indicate that the risk of falling is highest during the first few weeks after the initiation of a thiazide diuretic.10 Diuretics may contribute to the risk of falling by causing polyuria and dehydration-induced orthostasis, which may be treated with increased fluid and salt intake. To reduce fall risk, diuretics should be slowly titrated, patients can be interviewed to identify orthostatic symptoms, and patients can be counseled to drink fluids if they experience dizziness associated with low BP.11
In contrast, angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) have been associated with reduced fall risk.13 The mechanism of their protective effect is unknown, but may involve the preservation of muscle strength or vitamin D stores. ACEIs have been associated with reduced age-related deterioration in muscle strength, and renin-angiotensin system activation has been associated with vitamin D deficiency, an independent risk factor for falls.13 For elderly patients at high risk for falling, ACEIs and ARBs may be preferred first-line agents in treating uncomplicated hypertension. In addition to thiazide diuretics, a 1999 meta-analysis by Leipzig et al. found that the risk of falling was positively correlated with the use of type 1a antiarrhythmics or digoxin.3 Type 1a antiarrhythmics include disopyramide, quinidine, and procainamide and may increase fall risk via their anticholinergic properties or via QT-interval prolongation-induced ventricular tachycardia.11 Digoxin may also contribute to fall risk via its ability to precipitate cardiac arrhythmias, dizziness, and mental disturbances.11 The risk of falls may be minimized by avoiding digoxin doses greater than 0.125 mg daily and by avoiding the use of class Ia, Ic, and III antiarrhythmics until first-line treatments of atrial fibrillation (A fib) have been exhausted, as recommended by the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.8 First-line treatment options for rate control of A fib include nondihydropyridine calcium channel blockers and beta-blockers.14 Studies are mixed regarding the link between beta-blocker use and falls in the elderly; the 2009 meta-analysis of Woolcott et al. did not find a statistically significant association between beta-blocker use and falls.2 Nonetheless, clinical experience suggests that patients should be counseled when initiating or titrating a beta-blocker because several potential AEs, including orthostatic hypotension, bradycardia, fatigue, and dizziness, may increase patients’ risk of falling. As with other classes of medications, “start low and go slow” is the best approach to beta-blocker dose titration in elderly patients.
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Student Forum Table 2. Potential Adverse Effects of Atypical Antipsychotics That May Contribute to Fall Risk Drug
Dose-Related Extrapyramidal Symptoms
Prolactin Elevation
Anticholinergic Side Effects
Orthostatic Hypotension
Sedation
Aripiprazole
No
No
Very low
Low
Low
Asenapine
Yes
No
Very low
Low-moderate
Moderate
Clozapine
No
No
High
High
High
Iloperidone
No
No
Very low
Low-moderate
Low
Lurasidone
Yes
Yes
Very low
Low
Moderate
Olanzapine
Yes
Yes
Moderate
Low-moderate
Moderate
Paliperidone
Yes
Yes
Very low
Moderate
Low
Quetiapine
No
No
Moderate
Moderate
Moderate
Risperidone
Yes
Yes
Very low
Moderate
Low
Ziprasidone
Yes
Yes
Very low
Low
Low
Source: Reference 9.
Nonsteroidal Anti-inflammatory Drugs
Conclusion
NSAIDs have also been linked with an increased fall risk. This may be because of CNS side effects that occur in 1% to 10% of the population, including dizziness, headaches, drowsiness, mood alteration, and confusion.2,15 Certain NSAIDs in particular have been shown to have increased CNS side effects, including indomethacin and ketorolac.8 It remains unclear whether the association between fall risk and NSAID use should be attributed to CNS side effects or to the comorbid conditions that typically prompt NSAID prescribing, including arthritis and musculoskeletal pain. Nevertheless, it is recommended that elderly patients use acetaminophen preferentially to NSAIDs for musculoskeletal pain as acetaminophen has not been associated with an increased risk of falls.8,11 Opioids may be considered for moderate to severe pain, and topical NSAIDs, capsaicin, or other counterirritants may be considered for patients with localized musculoskeletal pain.16
It appears that the use of psychotropic medications, CV medications, and NSAIDs increase the risk of falls in the elderly. Because the elderly are much more likely to take multiple medications, pharmacological effects of these medications need to be evaluated as they may be additive or even synergistic in contributing to fall risk. Recommendations for minimizing fall risk caused by medications should involve well-planned tapering, discontinuation, and/or replacement of drugs implicated in falls. The elderly should also be educated on medication side effects and their proper administration to achieve optimal outcomes. Treatment with psychotropic medications, CV medications, or NSAIDs in elderly patients who have an increased risk of falling must include a thorough assessment of the risks and benefits that are likely to preserve function and quality of life.
416
The Consultant Pharmacist JUNE 2014 Vol. 29, No. 6
Medication-Related Falls in the Elderly: Prevention Strategies
Kristin L. Glab, MS, is a 2014 PharmD graduate, MCPHS, Worcester, Massachusetts. Fae Gwen G. Wooding, PharmD, is senior manager, Clinical Research Pharmacy, Pfizer Inc., Andover, Massachusetts. Kristin A. Tuiskula, PharmD, is clinical coordinator—medication safety, Department of Pharmacy Services, The University of Chicago Medicine, Chicago, Illinois. For correspondence: Kristin A. Tuiskula, PharmD, Department of Pharmacy Services, The University of Chicago Medicine, 5841 S. Maryland Ave. Rm. TE026, Chicago, IL 60637. Phone: 773-702-2154; Fax: 773-702-6631; E-mail: [email protected]. Disclosure: No funding was received for the development of this manuscript. The authors have no potential conflicts of interest. © 2014 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2014.413.
References 1. Huang AR, Mallet L, Rochefort CM et al. Medication-related falls in the elderly: causative factors and preventive strategies. Drugs Aging 2012;29:359-76. 2. Woolcott JC, Richardson KJ, Wiens MO et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 2009;169:1952-60. 3. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systemic review and meta-analysis: II. Cardiac and analgesic drugs. J Am Geriatr Soc 1999;47:40-50. 4. Allain H, Bentue-Ferrer D, Polard E et al. Postural instability and consequent falls and hip fractures associated with use of hypnotics in the elderly: a comparative study. Drugs Aging 2005;22:749-65. 5. Zammit G, Wang-Weigand S, Rosenthal M et al. Effect of ramelteon on middle-of-the-night balance in older adults with chronic insomnia. J Clin Sleep Med 2009;5:34-40.
6. Darowski A, Chambers SA, Chambers DJ. Antidepressants and falls in the elderly. Drugs Aging 2009;26:381-94. 7. Mehta S, Chen H, Johnson ML et al. Risk of falls and fractures in older adults using antipsychotic agents: a propensity-matched retrospective cohort study. Drugs Aging 2010;27:815-29. 8. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 2012;60:616-31. 9. Lexicomp Online, Geriatric Lexi-Drugs Online. Hudson, OH: Lexi-Comp, Inc.; November 7, 2013. 10. Gribbin J, Hubbard R, Gladman J et al. Risk of falls associated with antihypertensive medication: self-controlled case series. Pharmacoepidemiol Drug Saf 2011;20:879-84. 11. Cronin H, Kenny RA. Cardiac causes for falls and their treatment. Clin Geriatr Med 2010;26:539-67. 12. Aronow WS, Fleg JL, Pepine CJ et al. ACCF/AHA expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus documents developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. J Am Coll Cardiol 2011;57:2037-114. 13. Wong AK, Lord SR, Sturnieks DL et al. Angiotensin system-blocking agents are associated with fewer falls over 12 months in communitydwelling older people. J Am Geriatr Soc 2013;61:776-81. 14. American College of Cardiology Foundation, American Heart Association, European Society of Cardiology et al. Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation 2013;127:1916-26. 15. Hegeman J, van den Bemt BJ, Duysens J et al. NSAIDs and the risk of accidental falls in the elderly: a systemic review. Drug Saf 2009;32:489-98. 16. American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc 2009;57:1331-46.
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Introduction Falls are a leading cause of injury and injury-related death among the elderly population.1 The causes of falls are generally multifactorial; significant risk factors include dementia, neuromuscular disorders, muscle weakness, vision and hearing problems, environmental hazards, and polypharmacy.1 Several classes of medications, including psychotropic medications, cardiovascular (CV) medications, and nonsteroidal anti-inflammatory drugs (NSAIDs), have been associated with an increased risk of falls (Table 1).2,3 An understanding of how these medications contribute to fall risk should help guide fall-reduction programs and medication reviews for elderly patients. This article will review the medications commonly associated with falls in the elderly population, discuss possible mechanisms, and provide recommendations for preventing falls.
Psychotropic Medications Psychotropic medications include several drug classes commonly associated with falls: sedative-hypnotics, antidepressants, and antipsychotics.1 The use of a single psychotropic medication increases elderly patients’ fall risk by 30% to 80%, and the use of multiple psychotropic medications further increases fall risk.2-4 The anticholinergic and sedative properties of psychotropic agents are believed to be responsible for this increased risk.1 Anticholinergic adverse effects (AEs) associated with these medications include sedation, confusion, difficulty concentrating, hallucinations, delirium, and agitation. Hypnotic agents, including benzodiazepines, nonbenzodiazepine sedative-hypnotics, first-generation antihistamines, and barbiturates, may directly increase the risk of falling as a result of postural instability, prolonged sedation, and decreased psychomotor performance and cognitive function.4 Elderly patients taking these agents should be monitored for AEs and be educated on sleep hygiene to reduce the need for hypnotic agents. Optimizing the dose and dosing schedule of medications that contribute to insomnia can also help to minimize the use of hypnotic agents. Nonbenzodiazepine hypnotics, including zolpidem, zaleplon, and zopiclone, should
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Student Forum Table 1. Medications Associated with Falls Drug Class
Examples
Antidepressants
Amitriptyline, Bupropion, Citalopram, Fluoxetine, Mirtzapine, Nortriptyline, Paroxetine, Selegiline, Sertraline, Trazodone, Venlafaxine
Antipsychotics
Aripiprazole, Chlorpromazine, Haloperidol, Olanzapine, Quetiapine, Risperidone
Benzodiazepines
Alprazolam, Chlordiazepoxide, Clonazepam, Diazepam, Lorazepam
Cardiovascular Agents
Digoxin, Disopyramide, Procainamide, Quinidine
Diuretics
Acetazolamide, Bumetanide, Furosemide, Hydrochlorothiazide, Spironolactone, Triamterene
NSAIDs
Indomethacin, Ketorolac
Sedatives and Hypnotics
Chloral Hydrate, Hydroxyzine, Phenobarbital, Promethazine, Zaleplon, Zolpidem
Abbreviation: NSAIDs = Nonsteroidal anti-inflammatory drugs. Source: References 1-3, 8.
generally be recommended before benzodiazepines and agents with greater anticholinergic and sedation potential.4 Ramelteon may also be a safer option for elderly patients who have increased sleep onset latency.5 Nonetheless, the long-term use of any hypnotic agent should be avoided whenever possible.1 Both depression and the use of antidepressants are associated with an increased risk of falls.6 The risk is highest for patients who have recently initiated antidepressant therapy, before the drug has been able to improve the patient’s symptoms of depression. Additionally, fall risk appears to be dose-dependent, and for this reason, it is generally recommended that elderly patients start on a low dose of antidepressant and gradually increase the dose as tolerated.6 Tricyclic antidepressants (TCAs), tetracyclics, and trazodone are known to cause sedation, sleep disturbance with daytime drowsiness, and orthostatic hypotension via their effects on histamine receptors and α-adrenoreceptors.6 Selective serotonin-reuptake inhibitor (SSRI) use is associated with an increase in fall risk comparable to that of TCA use, but the mechanism by which SSRIs increase this risk is uncertain. SSRIs can cause sedation and orthostatic hypotension, but these side effects are
414
generally less common and less severe than those observed in patients taking TCAs. Instead, it may be that SSRIs increase the risk of falling through their central nervous system (CNS)-alerting effects such as sleep disturbance, insomnia, and nocturia.6 When these AEs lead to nighttime ambulation or daytime drowsiness, elderly patients may be at increased risk of falling. Sleep disturbance is an AE common to most antidepressant medications (as well as to depression itself), which may explain the increase in fall risk. In lieu of evidence that any particular antidepressant class is associated with a reduced risk of falling, the choice of antidepressant should be made based on side effect profiles and the potential for drug-drug interactions. Sedation and sleep disturbance may also play a role in the increased risk of falls associated with antipsychotic agents. Although typical antipsychotics have a greater incidence of extrapyramidal side effects (e.g., akathisia, pseudoparkinsonism, and dystonic reactions) when compared with atypical antipsychotics, studies have found that both classes of antipsychotic medications increase fall risk to a comparable degree.1,7 This observation may be explained by the serotonergic and histaminergic receptorblocking properties of atypical antipsychotics, which may
The Consultant Pharmacist JUNE 2014 Vol. 29, No. 6
Medication-Related Falls in the Elderly: Prevention Strategies
increase fall risk via sedation and orthostatic hypotension. Whereas CNS effects may directly increase the risk of falling, AEs that heighten the severity of fall-related injuries increase the likelihood that a fall will be recalled and reported, thereby increasing the apparent fall risk. For example, the long-term use of antipsychotics may increase the risk of fracture by inducing hyperprolactinemia and a reduction in bone-mineral density.7 Because of their AEs and the potential to increase the risk of falling and cerebrovascular accidents, antipsychotics should be reserved for elderly patients with a history of schizophrenia or schizoaffective disorder, and their use for off-label indications should be avoided unless therapeutic alternatives are unavailable.7,8 When it is necessary to treat a patient at risk of falling with an antipsychotic agent, side effect profiles can help guide drug selection (Table 2).
Cardiovascular Medications Antihypertensive agents may increase the risk of falling by causing postural, orthostatic, or postprandial hypotension; dizziness; syncope; or other CNS side effects (as in the case of centrally acting agents such as clonidine), especially while initiating or titrating antihypertensive therapy.10,11 The elderly, in particular, are at increased risk as a result of age-related physiological changes that influence blood pressure (BP) regulation and exacerbate these side effects.1,11 For patients 80 years of age or older, systolic BP of 140-145 mmHg is a reasonable BP goal if tolerated, but systolic BP goals of 130 and diastolic BP < 65 mmHg should be avoided because of concerns that vital organ perfusion may be reduced.12 Diuretics are the class of antihypertensive medications most consistently associated with falls.2-3,10 Recent studies indicate that the risk of falling is highest during the first few weeks after the initiation of a thiazide diuretic.10 Diuretics may contribute to the risk of falling by causing polyuria and dehydration-induced orthostasis, which may be treated with increased fluid and salt intake. To reduce fall risk, diuretics should be slowly titrated, patients can be interviewed to identify orthostatic symptoms, and patients can be counseled to drink fluids if they experience dizziness associated with low BP.11
In contrast, angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) have been associated with reduced fall risk.13 The mechanism of their protective effect is unknown, but may involve the preservation of muscle strength or vitamin D stores. ACEIs have been associated with reduced age-related deterioration in muscle strength, and renin-angiotensin system activation has been associated with vitamin D deficiency, an independent risk factor for falls.13 For elderly patients at high risk for falling, ACEIs and ARBs may be preferred first-line agents in treating uncomplicated hypertension. In addition to thiazide diuretics, a 1999 meta-analysis by Leipzig et al. found that the risk of falling was positively correlated with the use of type 1a antiarrhythmics or digoxin.3 Type 1a antiarrhythmics include disopyramide, quinidine, and procainamide and may increase fall risk via their anticholinergic properties or via QT-interval prolongation-induced ventricular tachycardia.11 Digoxin may also contribute to fall risk via its ability to precipitate cardiac arrhythmias, dizziness, and mental disturbances.11 The risk of falls may be minimized by avoiding digoxin doses greater than 0.125 mg daily and by avoiding the use of class Ia, Ic, and III antiarrhythmics until first-line treatments of atrial fibrillation (A fib) have been exhausted, as recommended by the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.8 First-line treatment options for rate control of A fib include nondihydropyridine calcium channel blockers and beta-blockers.14 Studies are mixed regarding the link between beta-blocker use and falls in the elderly; the 2009 meta-analysis of Woolcott et al. did not find a statistically significant association between beta-blocker use and falls.2 Nonetheless, clinical experience suggests that patients should be counseled when initiating or titrating a beta-blocker because several potential AEs, including orthostatic hypotension, bradycardia, fatigue, and dizziness, may increase patients’ risk of falling. As with other classes of medications, “start low and go slow” is the best approach to beta-blocker dose titration in elderly patients.
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Student Forum Table 2. Potential Adverse Effects of Atypical Antipsychotics That May Contribute to Fall Risk Drug
Dose-Related Extrapyramidal Symptoms
Prolactin Elevation
Anticholinergic Side Effects
Orthostatic Hypotension
Sedation
Aripiprazole
No
No
Very low
Low
Low
Asenapine
Yes
No
Very low
Low-moderate
Moderate
Clozapine
No
No
High
High
High
Iloperidone
No
No
Very low
Low-moderate
Low
Lurasidone
Yes
Yes
Very low
Low
Moderate
Olanzapine
Yes
Yes
Moderate
Low-moderate
Moderate
Paliperidone
Yes
Yes
Very low
Moderate
Low
Quetiapine
No
No
Moderate
Moderate
Moderate
Risperidone
Yes
Yes
Very low
Moderate
Low
Ziprasidone
Yes
Yes
Very low
Low
Low
Source: Reference 9.
Nonsteroidal Anti-inflammatory Drugs
Conclusion
NSAIDs have also been linked with an increased fall risk. This may be because of CNS side effects that occur in 1% to 10% of the population, including dizziness, headaches, drowsiness, mood alteration, and confusion.2,15 Certain NSAIDs in particular have been shown to have increased CNS side effects, including indomethacin and ketorolac.8 It remains unclear whether the association between fall risk and NSAID use should be attributed to CNS side effects or to the comorbid conditions that typically prompt NSAID prescribing, including arthritis and musculoskeletal pain. Nevertheless, it is recommended that elderly patients use acetaminophen preferentially to NSAIDs for musculoskeletal pain as acetaminophen has not been associated with an increased risk of falls.8,11 Opioids may be considered for moderate to severe pain, and topical NSAIDs, capsaicin, or other counterirritants may be considered for patients with localized musculoskeletal pain.16
It appears that the use of psychotropic medications, CV medications, and NSAIDs increase the risk of falls in the elderly. Because the elderly are much more likely to take multiple medications, pharmacological effects of these medications need to be evaluated as they may be additive or even synergistic in contributing to fall risk. Recommendations for minimizing fall risk caused by medications should involve well-planned tapering, discontinuation, and/or replacement of drugs implicated in falls. The elderly should also be educated on medication side effects and their proper administration to achieve optimal outcomes. Treatment with psychotropic medications, CV medications, or NSAIDs in elderly patients who have an increased risk of falling must include a thorough assessment of the risks and benefits that are likely to preserve function and quality of life.
416
The Consultant Pharmacist JUNE 2014 Vol. 29, No. 6
Medication-Related Falls in the Elderly: Prevention Strategies
Kristin L. Glab, MS, is a 2014 PharmD graduate, MCPHS, Worcester, Massachusetts. Fae Gwen G. Wooding, PharmD, is senior manager, Clinical Research Pharmacy, Pfizer Inc., Andover, Massachusetts. Kristin A. Tuiskula, PharmD, is clinical coordinator—medication safety, Department of Pharmacy Services, The University of Chicago Medicine, Chicago, Illinois. For correspondence: Kristin A. Tuiskula, PharmD, Department of Pharmacy Services, The University of Chicago Medicine, 5841 S. Maryland Ave. Rm. TE026, Chicago, IL 60637. Phone: 773-702-2154; Fax: 773-702-6631; E-mail: [email protected]. Disclosure: No funding was received for the development of this manuscript. The authors have no potential conflicts of interest. © 2014 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2014.413.
References 1. Huang AR, Mallet L, Rochefort CM et al. Medication-related falls in the elderly: causative factors and preventive strategies. Drugs Aging 2012;29:359-76. 2. Woolcott JC, Richardson KJ, Wiens MO et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 2009;169:1952-60. 3. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systemic review and meta-analysis: II. Cardiac and analgesic drugs. J Am Geriatr Soc 1999;47:40-50. 4. Allain H, Bentue-Ferrer D, Polard E et al. Postural instability and consequent falls and hip fractures associated with use of hypnotics in the elderly: a comparative study. Drugs Aging 2005;22:749-65. 5. Zammit G, Wang-Weigand S, Rosenthal M et al. Effect of ramelteon on middle-of-the-night balance in older adults with chronic insomnia. J Clin Sleep Med 2009;5:34-40.
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