Falls Risk Assessment

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Antidepressants

  • In a 2015 systematic review, antidepressants were found to be significantly associated with falls in seven studies, but not in nine studies.1
  • Side effects from this class of medication increasing the risk of falls includes sedation, orthostatic hypotension, cardiac arrhythmia effects, and anticholinergic effects such as blurred vision.2
  • Consider using preferred guidelines for all patients on antidepressants when determining the risk of relapse from dose reductions or withdrawals.3,4
  • Age, physical health and polypharmacy need to be considered before any action taken.7
  • Strong evidence to suggest that SSRIs increase falls risk as much or more compared to TCAs in elderly.1,4,5,6,7
  • It is difficult to establish which class of antidepressant is safest in elderly population based on multifactorial factors.1
  • Evidence suggests a trend between increased risk of falling and increasing doses of antidepressant agents.6
  • Strong evidence to suggest antidepressants in general are associated with a higher risk of hip fractures.6,7,8

SSRI

  • One study suggests the starting dose of an SSRI be 50% lower than the recommended adult dose in elderly patients.2,9
  • Avoid:
    • Paroxetine; greatest anticholinergic effects and strong sedative effects.2,3
    • Fluoxetine; long half-life increases risk of adverse effects in elderly.3
    • Fluvoxamine; risk of drug interactions, safer agents available.3
  • Agents of choice
    • Escitalopram and sertraline as they have the best harm-benefits ratio. Sertraline is the least likely to produce orthostatic hypotension or sedation, and few anticholinergic side effects.2,3
  • Citalopram has mixed evidence for risk of falls in elderly patients.6

SNRI:

  • Least studied of the antidepressant classes for falls risk.
  • Suggestive evidence that SNRIs cause greater orthostatic hypotension and can produce anticholinergic effects than SSRIs.2
  • Duloxetine has a lower incidence of anticholinergic effects.3

 TCAs

  • Sedation and postural hypotension are the biggest risk factor for falls.7
  • Agents of choice:
    •  Nortriptyline and desipramine as they have less anticholinergic effects than others, and are also less sedating.3
  • Agents to avoid:
    • Amitriptyline, doxepin, imipramine and trimipramine due to having the strongest sedating and anticholinergic effects.3

MAOI:

  • Avoid if at all possible due to risk of toxicity and drug interactions.3
  • Specialist use only.

Neuropathic pain

  • Consider tramadol, pregabalin and duloxetine at lower doses as they are less sedating and have less anticholinergic effects compared to alternative agents.3

References

  1. Park H, Satoh H, Miki A, Urushihara H, Sawada Y. Medications associated with falls in older people: systematic review of publications from a recent 5-year period. Eur J Clin Pharmacol 2015 September 26; 71:1429-1440.

  2. Van Leuven K. Psychotropic Medications and Falls in Older Adults. J Psychosoc Nurs 2010; 48(9):35-43.

  3. Ferreri S, Roth MT, Casteel C, Demby KB, Blalock SJ. Methodology of an ongoing, randomized controlled trial to prevent falls through enhanced pharmaceutical care. Am J Geriatr Pharmacother. 2008;6(2):61-81.

  4. Bulat T, Castle SC, Ruthledge M, Quigley P. Clinical practice algorithms: medication management to reduce fall risk in the elderly—part 3, benzodiazepines, cardiovascular agents, and antidepressants. J Am Acad Nurse Pract. 2008; 20(2):55-62.

  5. Browne Claire. Falls risk medication review tool. 2012 February.

  6. Coupland C, Dhiman P, Morriss R, Barton G, Hippisley-Cox J. Antidepressant use and risk of adverse outcomes in older people: population based cohort study. BMJ 2011 August 2; 343:1-15.

  7. Cumming RG. Epidemiology of Medication-Related Falls and Fractures in the Elderly. Drugs and Aging 1998 January; 12(1):43-53.

  8. Huang AR, Mallet L, Rochefort CM, Eguale T, Buckeridge DL, Tamblyn R. Medication-Related Falls in the Elderly. Causative Factors and Preventive Strategies. Drugs Aging 2012; 29(5):359-376.

  9. The American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc [Internet]. 2015 [cited 2017 Aug 10]; 63(11):2227-46. Available from: http://onlinelibrary.wiley.com/doi/10.1111/jgs.13702/epdf 

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