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Preventing Medication-Related Falls in Older Adults

chart showing falls, injuries, ed visits, hospitalizations, and deaths of older adults

Each year, 3 million older adults are treated in emergency departments for fall injuries.1 Falls are the leading cause of fatal and nonfatal injuries among persons aged 65 years (older adults).2 The direct medical costs for falls total nearly $30 billion annually.3

Healthcare providers can play an important role in preventing falls in older adults by identifying modifiable risk factors and intervening with appropriate evidence-based strategies. 

Medication interventions have been found to prevent falls and one randomized controlled study of gradual withdrawal of psychotropic medications reduced the rate of falls in older adults by 66%.

Which Medications Increase Fall Risk?

Polypharmacy, defined as using >4 medications, and the use of certain medications increase a patient’s risk of falling.3-5 Medications that cause sedation, dizziness, blurred vision, confusion, or orthostatic hypotension should be recognized as risk factors for falls.7

A recent meta-analysis found that antidepressants were the medication class most strongly associated with falls in older adults, with an odds ratio of 1.68.5 The following classes of medications have shown to increase fall risk:3

  • Psychoactive Medications
    • Antidepressants
    • Antipsychotics
    • Sedative Hypnotics
    • Benzodiazepines
  • Antihypertensives
  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Diuretics

Various criteria have been developed by experts to assess the quality of prescribing practices and medication use in older patients. One of the most widely recognized and frequently cited reference tools for assessing inappropriate drug prescribing is the AGS Beers Criteria®. The list of potentially inappropriate medications (PIMs) are discussed at length in our article Beers Criteria Updates with a Focus on Psychiatric Medications.

Beers Criteria and Fall Risk

The AGS Beers Criteria® includes the following medications as PIMs that should be avoided (unless safer alternatives are not available) as they may exacerbate a history of falls or fractures:9

  • Antiepileptics (avoid antiepileptics except for seizure and mood disorders)
  • Antipsychotics (may be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health conditions but should be prescribed in the lowest effective dose and shortest possible duration)
  • Benzodiazepines (shorter-acting benzodiazepines are not safer than long-acting ones)
  • Antidepressants (data for antidepressants are mixed but no compelling evidence that certain antidepressants confer less fall risk than others)
    • TCAs
    • SSRIs
    • SNRIs
  • Opioids (avoid except for pain management in the setting of severe acute pain (eg, recent fractures or joint replacement)
  • Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics (“Z-drugs”)
    • Eszopiclone
    • Zaleplon
    • Zolpidem

The rationale for including these medications as PIMs is the risk of causing ataxia, impaired psychomotor function, syncope, and additional falls. If one of the drugs must be used, consider reducing use of other CNS-active medications that increase risk of falls and fractures and implement other strategies to reduce fall risk.9

Preventing Falls in Older Adults

Optimizing drug therapy is an essential part of caring for an older person, however, clinicians face unique challenges when prescribing for older patients. The Centers for Disease Control and Prevention (CDC) developed the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative to help reduce fall risk among older adults. 

STEADI offers healthcare providers a streamlined approach to implementing the American and British Geriatrics Societies’ Clinical Practice Guideline for Prevention of Falls in Older Persons. STEADI consists of three core elements:

Centers for Disease Control and Prevention, 2021

Combined, these elements can have a substantial impact on reducing falls, improving health outcomes, and reducing healthcare expenditures.8

Medication Management for Fall Prevention

Medications that increase fall risk are considered to be a modifiable risk factor. Medication management can reduce interactions and side effects that may lead to falls. The CDC recommends that healthcare providers “identify medications that increase fall risk (e.g., Beers Criteria). The STEADI Fact Sheet: Medications Linked to Falls includes the following recommendations:8

  • Review medications with all patients 65 and older
    • Check for psychoactive medications
    • Review prescription drugs, over-the-counter medications, and herbal supplements.
    • Stop medications when possible
    • Switch to safer alternatives
    • Reduce medications to the lowest effective dose
  • Develop a patient plan that includes medication changes, and a monitoring plan for potential side effects. 
  • Implement other strategies, including non-pharmacologic options to manage conditions, address patient barriers, and reduce fall risk.

The CDC created the STEADI Fact Sheet: SAFE Medication Review Framework to help prevent older adult falls. This review framework uses the SAFE process: Screen, Assess, Formulate, and Educate:8

  • Screen for medications that may increase fall risk
  • Assess the patient to best manage health conditions
  • Formulate the patient’s medication action plan
  • Educate the patient and caregiver about medication changes and fall prevention strategies

The SAFE Medication Review Framework was adapted from existing medication therapy management tools that are developed and used by pharmacists. 

In Conclusion

Falls are the leading cause of fatal and nonfatal injuries among older adults. Healthcare providers can play an important role in preventing falls in older adults by identifying modifiable risk factors and intervening with appropriate evidence-based strategies.

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References

  1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–based Injury Statistics Query and Reporting System (WISQARS).
  2. Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged ≥65 Years — United States, 2014. MMWR Morb Mortal Wkly Rep 2016;65:993–998.
  3. Phelan EA, Mahoney JE, Voit JC, Stevens JA. Assessment and management of fall risk in primary care settings. Med Clin North Am. 2015;99(2):281-293. 
  4. Bradley SM. Falls in older adults. Mt Sinai J Med. 2011;78(4):590-595. 
  5. 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: 1952–1960.
  6. de Jong, M. R., Van der Elst, M., & Hartholt, K. A. (2013). Drug-related falls in older patients: implicated drugs, consequences, and possible prevention strategies. Therapeutic advances in drug safety, 4(4), 147–154. 
  7. Dellinger A. (2017). Older Adult Falls: Effective Approaches to Prevention. Current trauma reports, 3(2), 118–123. 
  8. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Stopping Elderly Accidents, Deaths, and Injuries (STEADI).
  9. By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;67(4):674-694.

Note (title image): Centers for Disease Control and Prevention. (2021, January 19). STEADI Our Staff for Fall Prevention [slide 6]. Centers for Disease Control and Prevention. https://www.cdc.gov/steadi/index.html

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