As "the leading cause of fatal and non-fatal injuries for our older Americans",1 we all know that falls have a huge impact on the quality and span of a resident's life in a long-term care community. The topic of fall prevention is a multi-faceted and complex one but one element we want to highlight is the effect that some medications and drug classes can have on the fall risk of an older adult and in particular the counter productive cascade effect of Polypharmacy, otherwise known as multiple medications.
Accora's recent webinar1 with DeLon Canterbury (The Deprescribing Pharmacist) focuses on which types of medications and common combinations can increase a person's fall risk and how healthcare professionals can go about Deprescribing in the most sympathetic manner. This article outlines a few of Dr Canterbury's top tips and takeaways on this topic from the webinar.
If you'd like to watch the full-length, on-demand webinar then you're very welcome to do so. Just follow the link at the bottom of this page.
According to Dr Canterbury, "Polypharmacy [is a] growing issue we have in this country. We unfortunately spend about half a trillion dollars every year in managing and honestly mismanaging medications and the harm that comes from that mismanagement of medications."
Polypharmacy or Hyperpolypharmacy is one of several known risk factors that can negatively affect a person's fall risk. Other risk factors include:
It is generally recognized that there are risk factors for falls such as dehydration, substance abuse disorders, fear of falling, sensory impairment and pain that are modifiable, and there are also non-modifiable risk factors such as age, gender, ethnicity and having a history of falls or strokes. Falls Risk Increasing Drugs or FRIDs are considered to be a modifiable risk and yet systematic monitoring for inappropriate medications too often falls to the bottom of the priority list in already over-stretched post-acute care environments.
Dr Canterbury states that "in addition, of course, in addressing the common side effects associated with falls, (dizziness or confusion) we may want to see if there's any medications that are the source of these issues."
Dr Canterbury explains by saying, "Generally what's defined as Polypharmacy is the use of five or more medications" and that "Hyperpolypharmacy is a newer term, not seen as much, for people who are taking more than ten prescriptions." It is also prudent to note that some organizations have different standards for these terms such as the Canadian Deprescribing Network which may work on the understanding that Polypharmacy be defined as four or more medications.
In drawing attention to a European study in older adults, Dr Canterbury states, "The addition of just one medication to the med list, led to a 3% association in mortality."1 This may lead us to believe that the complexities of combining medications as well as considering the number of prescriptions maybe linked to life expectancy and can negatively impact it.
In addition to this, we know that many injurious falls in the elderly population result in hip fractures, and it's known that the mortality rates post hip fracture for over 65-year-olds are not encouraging. So, in considering the effects of Polypharmacy on fall rates, we must also assess the correlating relationship between mortality from fall-related injuries and fall-risk-increasing drugs.
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Dr Canterbury recommends that caregivers become familiar with the US Deprescribing Network and the Canadian Deprescribing Network as free and reliable sources of information about the facts of Polypharmacy and the effects of Deprescribing strategically.
The following figure is taken from the Canadian Deprescribing Network3 and it shows which medication classes have the biggest impact on falls risk. In addition to this, the presence of Polypharmacy proved to increase a person's risk of falling by 75%. This shows that it isn't necessarily only a case of which classes of medications can increase risks but also the combinations and overall count that can have a fatal impact.
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Dr Canterbury also advises that "at least in the US, in the last two years, we are seeing a bit of a decline in the use of opioids and antipsychotics, but we are seeing a huge uptake in the use of these anticonvulsants or antiepileptics and [...] we want to make sure that we aren't just swapping one problem for another."
As we can see from the chart, a person's fall risk is 1.5-2 times higher if they are taking 4 or more medications (depending on which definition of Polypharmacy you subscribe to). This also then has a financial implication as we know that fall root cause analysis, medication reviews and extra nurse documentation all add up to the cost of a fall and that's just for a fall without injury.
So what's the solution? Dr Canterbury recommends a "team-based approach" such as the STEADI SAFE Deprescribing Framework. He also highlights the importance of resident communication, saying that "as we're switching or reducing doses we want to make sure the patient is empowered and educated on what's going on and make sure we're discussing what may happen as things flare up or there are any resurfaces of the chronic condition. The philosophy is to keep Deprescribing as much as we can until there's a point when we can no longer clinically do that."
As we age, the body becomes less able to process substances and drugs as efficiently, often resulting in more side effects and fewer benefits from the medications we are routinely taking. It's entirely feasible that many older adults are still taking medications that are no longer appropriate for them or in an inappropriate dose.
A systematic review of medications in our older adult population is a key way that we can strategically Deprescribe before the risk of harm is too great and therefore prevent injurious falls. Reviewing medications reactively in response to fall incidents, transfers of care and injuries is not necessarily the best way to ensure a low fall risk at every stage of the resident's care journey.
We can't always know for sure whether injurious falls were specifically caused by medication-related factors but implementing a process that allows care providers to periodically review opportunities for Deprescription before accidents occur is surely advisable.
As we've said, fall prevention is a complex and multi-faceted puzzle and not all falls are preventable. However, we're always learning more about our elderly population and fall-risk-increasing drugs. Because of this, we can't assume that what was best practice yesterday, still is today.
On the part of clinical caregivers and pharmacologists, constant learning and where possible, constant improvement, is required to ensure the delivery of quality care. So, staying curious about inappropriate medications and Deprescribing where possible can only be a good thing.
Interested in learning more about which specific drug classes affect fall risk in older adults? Watch the full webinar with Dr DeLon Canterbury, The Deprescribing Pharmacist of GeriatRx. Follow the link below to access the free recording.
1 - 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
2 - Morri, M., Ambrosi, E., Chiari, P. et al. One-year mortality after hip fracture surgery and prognostic factors: a prospective cohort study. Sci Rep 9, 18718 (2019). https://doi.org/10.1038/s41598-019-55196-6
3 - Deprescribing Network. (n.d.). Medications and falls. Retrieved from https://www.deprescribingnetwork.ca/medications-and-falls
