Antidepressants, opioids more than double falls risk in older people

Evelyn Lewin

4/06/2019 3:12:10 PM

Practitioners need to weigh up the risks and benefits of these medications, expert says.

Fallen older person
‘Fracture is no small thing in older people. It can be life-changing,’ Professor Dimity Pond, a GP with a special interest in dementia and aged care, said.

An older person who takes an antidepressant or opioid more than doubles their risk of a fall and hip fracture.
That is what new research, published in the latest edition of Australian Prescriber, has found.
While the association between certain drugs and an increased risk of falls is well recognised, this research shines a new light on how close that relationship is.
Researchers tested five groups of drugs:

  • Antidepressants (selective serotonin reuptake inhibitors [SSRIs])
  • Opioids
  • Antiepileptic drugs
  • Benzodiazepines
  • Antipsychotics
They found the risk of hip fracture increased for all five groups.
The highest risk of hip fracture – a fivefold increased risk – was when a benzodiazepine and an SSRI were started together. This equated to one extra hip fracture for every 17 patients aged 80 years and over treated for a year.
‘I’m not surprised,’ Professor Dimity Pond, a GP with a special interest in dementia and aged care, told newsGP after looking at these findings.
‘I think there’s a lot of reasons for us to reduce the number of medications that we provide for older people, and falls [risk] is one of them.
‘Then you need to balance up the benefits [of medication] against the risk.
‘Fracture is no small thing in older people. It can be life-changing.
‘People who fracture their hip, a high percentage of them don’t get back to walking as they used to – or at all – and there’s a high mortality after a fracture, so we really do need to take these medications very seriously.’
According to the research, an estimated 30% of people in Australia aged over 65 years living in the community, and 50% of residents of aged care facilities, fall at least once a year. Furthermore, an estimated 28,000 people aged over 50 years were hospitalised for a hip fracture in 2018.
The researchers noted that the medications prescribed, such as benzodiazepines and antidepressants, may not be safe and a patient’s risk of falls should be assessed before they are prescribed.
Instead of prescribing an antidepressant for mild or moderate depression, for example, they recommended psychological management alone as an appropriate first-line treatment.
Professor Pond agrees that such medication comes with risks in elderly patients. However, she said, those risks need to be weighed up with their potential benefits.
‘If they’re elderly, we have to weigh up the balance: the risk of falls and the risk of exacerbating cognitive impairment, against the awfulness of living with depression as an older person,’ she said.
The same logic can be applied to pain and its treatment.
Professor Pond said it is also vital to check that medications prescribed in an older population are actually working.
‘[Antidepressants] don’t work well in people with dementia, for example, [so] it might not be the best thing to do [to prescribe them for such people],’ she said.
The authors suggest reviewing and modifying an older patient’s medicines and gradually withdrawing psychotropic drugs in order to reduce the risk of falls.
‘If de-prescribing, stop one drug at a time and wean doses slowly over weeks or months while closely monitoring the patient for benefits or adverse effects,’ the authors state.
‘Stopping too quickly can cause withdrawal syndromes.’
Other medication suggestions included, when possible, slowly tapering and ceasing or substituting with a non-opioid analgesic for older patients taking opioids for chronic pain, avoiding starting benzodiazepines, and limit doses and duration of treatment with antipsychotics.
When prescribing medication for older patients, Professor Pond said it is best to start with low doses.
‘The recommendation is always to “start low and go slow”,’ she said. ‘So start with a low dose for long enough and measure whether it’s working or not.
‘Ask the person, “Do you feel happier?” or, “Are you in less pain?”
‘Maybe even use a scale of some sort and then maybe bump [the dose of the medication] up a little bit, but maybe not the maximum quantity, given their age and renal impairment and so on.
‘And all of it has to be done in collaboration with the person and their family.’
Encouraging patients to work with a range of health professionals to help them stay active and socially connected can help reduce an older person’s risk of falls, the authors state. Exercise programs and home safety interventions can also help, as can encouraging patients to report adverse effects that can increase falls risk, such as dizziness, confusion or blurred vision.
‘There’s a lot of things that can be done to try and reduce falls,’ Professor Pond said.
That includes checking a patient’s footwear, balance and vision, and ensuring patients who are advised to use walking aids actually use them.
Another factor to consider when discussing falls risk is bone health. The authors recommend identifying patients at risk of poor bone health, referring them for a mineral-density scan if needed.
While this new research does not surprise Professor Pond, she believes it highlights the ‘complexity of looking after older people’ and shows that GPs need to spend enough time on these complex issues.
‘I can’t resist saying that we need to be adequately remunerated for that time, or it won’t happen,’ she added.

antidepressants elderly falls risk fracture risk opioids


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Joel Rhee   5/06/2019 3:57:02 PM

Is it true to say that antidepressants double the risk of falls? The linked article indicates that they increase the risk of hip fractures but I don't think it is the case for falls. Presumably the higher risk of hip fracture is due to SSRI and their effect on bone mineral density. I think the NPS article has a link to a systematic review / meta analyses that showed some link between depressive symptomatology and falls, but they didn't find any convincing link between antidepressant use and falls. So, while I agree with the main recommendations here, there should be more clarity around antidepressant use and how it contributes to hip fractures in elderly people.
The other issue is access to psychologists. I don't know of many (if at all) psychologists who do home visits for frail, older patients (and at a reasonable price).