.png)
When it comes to the prevention of falls in the elderly population, one of the key things we might need to be very aware of is the number of medications a resident is taking. This is also known as Polypharmacy and can have a significant effect on an older adult's fall risk, especially in long-term care settings where falls are statistically more likely to occur versus in the community1.
For more information on the connection between multiple medications and the risk of falls, you might like to see our recent article: Polypharmacy and falls risk in the older adult population.
If, however, you want to find out more about the specific drug classes that influence fall rates in elderly people and how to go about Deprescribing fall-risk-increasing drugs (FRIDs) appropriately then keep on reading...
According to the Canadian Deprescribing Network2, the following medication classes have been proven to have the biggest impact on fall risk.
.jpg)
In our recent webinar3, Dr DeLon Canterbury advised, "We need to know what are the key medication classes associated with these falls. We're imploring people to simply stop medicating whenever it's possible and switch to safer alternatives as needed. If we're going to do anything, we're going to want to reduce to the lowest form of the effective dose so always start low, go slow and [...] ensure we're looking out for the meds such as anticonvulsants, our antidepressants, antipsychotics, our benzodiazepines, our opioids and of course, our sedatives."
Some key categories of drugs that can have an adverse effect on fall risk in older adults and what Dr Canterbury has to say on the subject of their use in long-term care.
Dr DeLon Canterbury explains the issue with prescribing Benzodiazepines as anti-anxiety medications. "Frankly, we simply see them a lot that they were once for anxiety and now they are thrown on indefinitely because, well because they've been on it for 10-20 years. But Benzos are not at all noxious and I think we know that this is one of the big ones, especially when combined with alcohol, opioids and other falls risk worsening drugs."
Dr Canterbury recommends that, "We're always going to want to taper these off in a supervised and slow manner. I hate when I hear patients have been taken off this medication just cold turkey within transitions of care. It really doesn't make sense and you're increasing the risk of seizures in doing that especially when people have, again, been on this for quite some time. And these aren't easy to deprescribe; these are pretty hard, so you really are going to have to get to making a plan that's customized to the patient's needs but think about doing this super long-term.
“There isn't a perfect plan to do this. It's all going to be based on patient response, withdrawal of symptoms and of course, what we were trying to manage before. We want to go super low and go super slow."
Opioids are often used for pain management and there are certainly arguments for this, but changes in how the human body can process certain substances as we age can increase the adverse effects of opioids in older adults. As context, Dr Canterbury advises that 50 MME (Morphine Millimetre Equivalents) per day should be classed as high-risk opioid use.
He also advises that "generally speaking, we know the common side effects of opioids [...] sedation and dizziness - absolutely - but one that I don't want us to miss is orthostatic hypotension. Opioids can increase the risk of that.
Dr Canterbury states, "there isn't a cookie-cutter-perfect way to address this. You're going to want to assess what type of pain, [...] have we exhausted other non-pharm strategies first? You know, have we done a number with liniments, massage therapy, ointments? Have we considered physical therapy, water aerobics, exercise? Have we addressed the psychological component of pain? Pain is biological, it's social and it's psychological."
Again, the general advice is to do this slowly for Deprescribing, but also to thoroughly assess other pain management options before looking to Opioids for blanket pain relief solutions.
After the opioid epidemic, there has generally been thought to be a marked improvement in Opioid Deprescribing and Antipsychotic prescribing, by which we mean a decline in prevalent use. However, Dr Canterbury stresses that "all psychotropic drug classes are associated with an increased risk of falling. They all have these risks. Additionally, they also have this risk of mortality when used for the behavioral management of Dementia and a cardiovascular risk associated with that as well.
Dr Canterbury recommends looking deeper at the root cause of the symptoms we're trying to treat with Seroquel or similar antipsychotic drugs before prescribing these, especially to treat depressive disorders and the symptoms of depression.
Deprescribing.org have excellent guidelines regarding antipsychotic Deprescribing which urges caregivers and prescribers to first consider why the patient is taking this type of medication. Similarly, Dr. Canterbury advises that we should start with the question, "Why are they on antipsychotics to begin with? Are we using this for insomnia or are we using this for schizophrenia or delirium, or are we using this for psychosis, aggression and agitation?
"Now, if we're talking more about psychosis, aggression, agitation? We're going to want to consider a recommendation to taper and stop."
According to Dr Canterbury, "anticonvulsant use is very much on the rise" and with an average increased fall risk for their use of 55%, it's always a good idea to look again at whether they need to be taking this drug class for their condition. Teepa Snow recommends a non-pharmacological approach to behavior management for those with Behavioral and Psychologic Symptoms of Dementia (BPSD) and Dr Canterbury wholeheartedly agrees. He supports training clinical caregivers in a personalized and individualized approach to dementia care "before we jump on using another medication."
Often anticonvulsants are used to treat symptoms of Dementia, but Dr Canterbury advises that "there is really no evidence for the use of these types of meds for that health condition. [...] We have to question every time we see this: was there truly a seizure history and if there were behavioral triggers that caused aggression and behaviors in the past, have those triggers been assessed or removed?"
It's prudent when systematically reviewing a person's medical prescriptions to also consider alternative medications and non-prescription items in order to ensure an accurate assessment of their intake of substances and an in-depth understanding of where we can improve quality of life while reducing risk factors for falls.
Dr Canterbury advises, "When we're doing these medication reviews, do not neglect our over-the-counter medications. Do not neglect herbal medications and vitamins as well. We want to be thorough and make sure we're not contributing to any changes in cognitive impairment, especially with certain first-generation antihistamines we may see have a high anticholinergic burden and may be inappropriate for those with Dementia."
According to Dr Canterbury, there are many obstacles and challenges healthcare professionals may face when attempting to deprescribe certain drugs and medications. He advises that "you know we're all human, they're going to do what they want to do and some may attempt to stop/deprescribe themselves. They may have done it in the wrong way without medical supervision or they may have done it too aggressively, causing harm to themselves."
In addition to this, some residents may face emotional challenges through deprescribing and we need to be prepared for that. Dr Canterbury says, "We want to make sure that we appreciate the psychological attachments of some of these medications and understand that there is a heightened anxiety when people have been on this for a while are considering getting off of them."
The benefits of Deprescribing drugs that can negatively impact fall risk are certainly far-reaching but it can sometimes feel like an overwhelming project to undertake. Dr Canterbury suggests that the US Deprescribing Research Network, Deprescribing.org and the the STEADI toolkit from the CDC are great places to start for anyone with a hand in the care of older adults. All these organizations offer free, evidence-based toolkits and resources to help you assess appropriate opportunities for Deprescribing and preventing falls.
1 - Nursing Home Abuse Center. (n.d.). Falls& fractures in nursing homes. Retrieved from https://www.nursinghomeabusecenter.com/nursing-home-injuries/falls-fractures/#:~:text=Between%2050%25%20and%2075%25%20of,falls%20in%20any%20given%20year.
2 - Deprescribing Network. (n.d.). Medications and falls. Retrieved from https://www.deprescribingnetwork.ca/medications-and-falls
3 - Canterbury, D., Accora., (2024). Identifying deprescribing opportunities to reduce falls risk in older adults [Webinar]. Retrieved from https://us.accora.care/webinars/identifying-deprescribing-opportunities-to-reduce-falls-risk-in-older-adults
