Falls and medication
20th Apr, 2021

 Falls and medication


A recent study published in Pharmacoepidemiology and Drug Safety found that in 2017, 94% of adults 65 years and older in the United States were prescribed at least one drug that elevated the risk of falling, a significant increase from 57% in 1999. This trend was concurrent with a substantial increase in deaths related to falls among older adults (1). 

Falling in elderly adults is a significant yet under-recognised public health concern. Globally, more than 30% of people aged 65 years and above fall each year (2). Falls are the primary reason for 85% of all injury-related admissions to hospital and more than 40% of nursing home admissions (3). Furthermore, falls are the leading cause of injury-related death for those 70 years and older (4). The annual costs associated with falls and fall-related complications were estimated to be $50 billion in 2015 in the United States alone (5).

Fall risks are multifactorial and include a combination of physiological, psychological, health and environmental factors (6,7). Several studies have associated polypharmacy and certain drugs with an increased risk of falls in the elderly (8,9,10,11).

The most common drugs that increase the risk of falls are psychotropic drugs, such as hypnotics, sedatives, antipsychotics, and antidepressants, which can cause sedation and impaired balance and coordination. Antihypertensive drugs and diuretics may cause or worsen orthostatic hypotension and falls (1,2). 

A recent meta-analysis found that deprescribing interventions based on a medicine review resulted in a relative risk reduction of 24% in the number of older adults who fell (12).

The current study is a cross-sectional analysis utilising data on fall-related deaths and prescription fills among US adults 65 years and older. Data was obtained from both the National Vital Statistics System (NVSS) and the Medical Expenditure Panel Survey (MEPS) for years 1999-2017 (1).

During the study period, there was a significant increase in fall risk-increasing drug (FRID) use. More than 560 million adults aged 65 years and older received at least one FRID during this period and filled more than 7.8 billion prescriptions. The majority of prescriptions were for antihypertensives (71.2%). However, there was also a significant increase in antidepressant prescription fills, from 12 million in 1999 to more than 52 million in 2017. 

The use of FRIDs was considerably higher among females, which is relevant as the female gender is identified as an independent risk factor for falls and fractures (1). 

Prescribing of multiple FRID classes also increased over the study period. Opioids and antihistamines were the most commonly co-prescribed drug classes, with nearly 24 million people (14% of total) prescribed this combination.   

From 1999-2017, 374,972 fall-related mortalities were recorded. Age-adjusted mortality due to falls increased from 29.40 per 100 000 in 1999 to 63.27 per 100 000 in 2017. The most significant increase in deaths from falls, rising 160% between 1999 and 2017, occurred in white women aged 85 years and older.

The current study has several limitations. Due to its cross-sectional design, the study cannot prove causality between the increased exposure to FRIDs and fall-related mortality. Furthermore, the study did not account for the increasing prevalence of comorbidities and only included data for a non-institutionalised population. 

Nonetheless, the study indicates fall risk-increasing drugs may partially explain the increase in mortality due to falls. The findings support guidelines for falls prevention in the elderly, emphasising the benefit of medication reviews and medication reduction as crucial interventions (13,14). 

1Shaver AL, Clark CM, Hejna M, Feuerstein S, Wahler Jr RG, Jacobs DM. Trends in fall‐related mortality and fall risk increasing drugs among older individuals in the United States, 1999–2017. Pharmacoepidemiology and drug safety. 2021 Feb 3.
2Sharif SI, Al-Harbi AB, Al-Shihabi AM, Al-Daour DS, Sharif RS. Falls in the elderly: assessment of prevalence and risk factors. Pharm Pract (Granada). 2018 Jul-Sep;16(3):1206.
3Woolcott JC, Richardson KJ, Wiens MO, Patel B, Marin J, Khan KM, Marra CA. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Archives of internal medicine. 2009 Nov 23;169(21):1952-60.
4James SL, Lucchesi LR, Bisignano C, Castle CD, Dingels ZV, Fox JT, Hamilton EB, Henry NJ, Krohn KJ, Liu Z, McCracken D, Nixon MR, Roberts NLS, Sylte DO, Adsuar JC, Arora A, Briggs AM, Collado-Mateo D, Cooper C, Dandona L, Dandona R, Ellingsen CL, Fereshtehnejad SM, Gill TK, Haagsma JA, Hendrie D, Jürisson M, Kumar GA, Lopez AD, Miazgowski T, Miller TR, Mini GK, Mirrakhimov EM, Mohamadi E, Olivares PR, Rahim F, Riera LS, Villafaina S, Yano Y, Hay SI, Lim SS, Mokdad AH, Naghavi M, Murray CJL. The global burden of falls: global, regional and national estimates of morbidity and mortality from the Global Burden of Disease Study 2017. Inj Prev. 2020 Oct;26(Supp 1):i3-i11.
5Florence CS, Bergen G, Atherly A, Burns E, Stevens J, Drake C. Medical costs of fatal and nonfatal falls in older adults. Journal of the American Geriatrics Society. 2018 Apr;66(4):693-8.
6Sharif SI, Al-Harbi AB, Al-Shihabi AM, Al-Daour DS, Sharif RS. Falls in the elderly: assessment of prevalence and risk factors. Pharmacy Practice (Granada). 2018 Sep;16(3).
7Zhuang M, Li J, Chen H, Yang Y, Li P, Shi L, et al. Research Progress on Risk Factors and Prevention Strategies of Falls in Elderly Inpatients. International Journal of Clinical and Experimental Medicine Research. 2021;5(2):101–5.
8Gnjidic D, Hilmer SN, Blyth FM, Naganathan V, Waite L, Seibel MJ, McLachlan AJ, Cumming RG, Handelsman DJ, Le Couteur DG. Polypharmacy cutoff and outcomes: five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes. Journal of clinical epidemiology. 2012 Sep 1;65(9):989-95.
9Aspinall SL, Springer SP, Zhao X, Cunningham FE, Thorpe CT, Semla TP, Shorr RI, Hanlon JT. Central nervous system medication burden and risk of recurrent serious falls and hip fractures in veterans affairs nursing home residents. Journal of the American Geriatrics Society. 2019 Jan;67(1):74-80.
10Hanlon JT, Zhao X, Naples JG, Aspinall SL, Perera S, Nace DA, Castle NG, Greenspan SL, Thorpe CT. Central nervous system medication burden and serious falls in older nursing home residents. Journal of the American Geriatrics Society. 2017 Jun;65(6):1183-9.
11Hart LA, Marcum ZA, Gray SL, Walker RL, Crane PK, Larson EB. The association between central nervous system‐active medication use and fall‐related injury in community‐dwelling older adults with dementia. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. 2019 May;39(5):530-43.
12Kua CH, Mak VS, Lee SW. Health outcomes of deprescribing interventions among older residents in nursing homes: a systematic review and meta-analysis. Journal of the American Medical Directors Association. 2019 Mar 1;20(3):362-72.
13Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. Journal of the American Geriatrics Society. 2011 Jan;59(1):148-57.
14Waldron N, Hill AM, Barker A. Falls prevention in older adults: assessment and management. Australian family physician. 2012 Dec;41(12):930-5.