Statement of the Problem
High morbidity rates among the elderly population are largely attributed to falls. Thirty four percent of the seniors aged over 60 years fall at least once in a year with a higher percentage of falls being experienced among frail elderly individuals living in aged residential homes. Falls not only cause injury leading to hospitalization but also lead to anxiety, depression and physical immobility. Moreover, the U.S., reports of fall-related injuries and other complications in aged care homes are on rise. In financial terms, providers incur huge costs due to injuries sustained by elderly persons within the nursing home settings. As such, studies that investigate the fall risk factors are important as they give insights on the causes of falls and how the fall risks can be avoided.
Psychotropic medications including commonly used drugs have been found to contribute greatly to falls in elderly individuals. However, differentiating the specific medications that cause falls from those that do not is a challenge in clinical practice. Several studies have examined the relationship between specific psychotropic drugs and the likelihood of experiencing falls during the study period; but, differences in methodology, definitions of the falls and setting make it difficult to make conclusions about the impact of psychotropic drugs on falling in seniors. Althogh the use of psychotropic medications has continued to rise, research evidence indicate that certain classes of these medications cause falls among seniors.
Using articles from various databases, this paper will analyze the association between use of psychotropic medications and falling in seniors. A meta-analysis of study data including drug classes, age of participants and fall frequency from recently published studies will help determine whether or not psychotropic medications increase falling in elderly individuals. Conclusions will be made based on the findings of critical appraisal of relevant literature.
Research Question
Over the past few years, there has been increasing recognition that some psychotropic medications cause falling in elderly people. This paper will explore the research question that: Does the Use of Psychotropic Medications Increase the Risk of Falls Compared to the Non Use of Psychotropic Medications in the Elderly Population?
Literature Review: The Search
A computerized literature search of articles published between 1999 and 2012 was conducted on CINAHL, MEDLINE and EBM to identify relevant studies for inclusion. The search was conducted based on the methodology described by Garrard. In the search, several MeSH terms were used including ‘therapeutic uses’ that was combined with terms like ‘home accident’ or ‘accidental falls’. Advanced searches were done using subheadings derived from the Mesh terms. Moreover, another search using the terms, ‘pharmacoepidemiology’ and ‘epidemiology’ combined with ‘home accident’ or ‘accidental falls’ was conducted on all the databases. Studies related to the topic were included in the final assessment.
The inclusion/exclusion criteria was based on whether the researchers collected original data or they relied on secondary sources of data and the study design employed Six met the inclusion criteria and were included in the final appraisal.
Literature Review: The Matrix
Passaroet al., 2000 Dec. Benzodiazepines with different half-life and falling in a hospitalized population: The GIFA study. GruppoItaliano di Farmacovigilanzanell’Anziano.J ClinEpidemiol.
Level 2 evidence; a prospective study. The use of benzodiazepines is not a risk factor for falls in elderly people. Benzodiazepines, Falls. Recent evidence indicates that the use of benzodiazepines is a major risk factor for falling in seniors. Based on this observation, this study aimed to evaluate the role of various benzodiazepines in falls in elderly care facilities. Non-randomized controlled clinical trial. Sample size was 7908 patients; 58 clinical centers. Survey forms. Of the 7980 patients followed in this study, 2.2% experienced falls during the study period. 3.2 % of patients who took benzodiazepine experienced falls compared to 1.9% for the control group.
The findings indicate that the use of benzodiazepines that have a short half-life increase the risk of falls among elderly patients. Thus, elderly patients must be evaluated properly before being put under psychotropic medication.
Frels, Willia, Narayanan &,Gariball; 2002 Aug. Causes of hospital falls among elderly patients. Postgrad Med. J.
Level 3; A case-control study. Understanding the fall risk factors does not help in formulation of strategies to prevent falls among the elderly people. Temazepam medication. Falls. There is an urgent need for evidence to support the strategies employed to prevent falls among the elderly. Alternative medications should be sought to replace benzodiazepines. A Case-control research design. 181 elderly bpatients. Survey forms. In this study, 46% of the fallers were under benzodiazepines compared to 27% of fallers in control group.
There an urgent is need for an alternative to benzodiazepines for elderly patients Landiet al., 2005 May; Psychotropic medications and risk for falls among community-dwelling frail older people: an observational study. J Gerontol A BiolSci Med Sci.
Level 3; observational study. The use of psychotropic medications from different classes enhance the fall risk among elderly people. Benzodiazepines, antidepressants, Nonbenzodiazepine, antipsychotic drugs and sedative-hypnotics, falls. Injuries resulting from falls raise much concern especially for elderly people. Most of these falls have more than one cause and often involve an interaction between internal and external factors. Observational study. The sample size was (n = 2854, of elderly people admitted to nursing homes under the Italian Silver Network Home Care project. Survey forms.
Psychotropic drugs of any class caused an increase in the risk of fall by 47% (OR, 1.47); Also, users of atypical antipsychotic medications experienced an in increasing fall risk (OR, 1.45). Prescribing short-acting benzodiazepines for sedating the elderly instead of long-acting agents may substantially lower the fall risk.
Lawlor, Patel &,Ebrahim. 2003 Sep. Association between falls in elderly women and chronic diseases and drug use: cross sectional study. BMJ
Level 3; Cross-sectional study. There is no connection between falling, drug use and chronic diseases and drug among elderly women. Chronic diseases; circulatory disease, COPD, depression, and arthritis, falls. Although psychotic drugs play a role in determining falling in elderly people, chronic conditions also contribute to falls
Cross-sectional study. 4050 elderly women (aged 60-79 years). Surveys.The risk of falling increasing by 32.2%with the rise in the number of chronic illnesses affecting the patient. Chronic disease is a major predictor of falling among elderly women, compared to psychotropic drugs.
Rozenfield, Camacho&,Veras, 2003 Jun; Medication as a risk factor for falls in older women in Brazil. Rev PanamSaludPublica.
Level 3. There is no association between falls use of medications by elderly people living in residential care homes. Psychotic medications, Non psychotic medications,
Falls. Non-psychotic drugs including OTC beta-blockers and diuretics used by elderly people increase the risk of falling for people living in the community settings. Cross-sectional. 634 elderly women. Questionnaires, Interviewing. In the study, 23.3%of participants reported to have fallen once in the previous year, while 14% reported falling more than twice in the previous year. There is an connection between recurrent falls and drug use; most falls can be avoided through better drug use
Hienet al., 2005 Aug; Atypical antipsychotic medications and risk of falls in residents of aged care facilities. J Am Geriatr Soc..
Level 4. There is no association between the use of atypical antipsychotics and the reduced fall risk. Atypical antipsychotics (Olanzapine, Risperidone) and typical antipsychotics, falls. There has been some evidence suggesting that the use of atypical antipsychotics could have a reduced risk of falls compared to typical antipsychotics
Prospective cohort study. 1,107 subjects. Survey forms. 11% of subjects(n=226) experienced at least one fall during the study period. Atypical antipsychotic medications do not result to lower fall-related incidences compared to psychotropic medications
Literature Review: Critically Appraise the Evidence
The six studies varied in outcomes, research design, level of evidence, study setting (long-term care facility or community), the age of the participants and time and method of ascertaining the falls. Two studies involved a cross-sectional study design, others were a prospective cohort study, a case control study, cross-sectional and non-randomized controlled clinical trial with varied levels of evidence. Other differences relate to mean age of the participants (more than 60 years) and the method of ascertaining the medications. All these studies except one (Lawlor, Patel,&Ebrahim, 2003) examined the role of antipsychotic and psychotropic medications in patient falls.
The studies confirm that there is an association between use of psychotic medications and falls in elderly individuals across all settings. Five of these studies (Hienet al., 2005; Rozenfield, Camacho, &Veras, 2003; Landiet al., 2005; Frels, Willia, Narayanan &Gariball, 2002; and Passaroet al., 2000) supported the finding that psychotropic medications increase the fall risk among elderly people. On the other hand, (Lawlor, Patel &Ebrahim, 2003)finding was compelling; it compared the effect of chronic diseases and psychotropic medications on falling among elderly patients.
Of the six studies, five had a significant treatment effect of between 11% and 46%, one had a treatment effect of 2.2%. These results indicate that psychotropic medications or antipsychotics have side effects on elderly individuals and their use substantially increases the risk of falling. The probability of falling was high for medication classes of benzodiazepines, antipsychotics, sedatives and antidepressants. The studies assessed the different classes of psychotropic medications, mode of administration and the associated risks but fail to examine the underlying mechanism of action. As such, further research is needed to examine the effect of psychotropic medications on cognitive functioning of elderly persons.
Conclusion
Psychotropic medications have been identified as a risk factor for patient falling. Nevertheless, not many randomized controlled trials have been done to assess the effect of specific psychotropic medication classes on falling among elderly people. The results of this analysis establish that psychotropic medications should be prescribed to seniors with great caution. There is sufficient evidence from observational studies that psychotropic medications contribute to falls in elderly persons. Future research should focus on long-term care and community care settings to provide quality data on fall risks for use by pharmacists and physicians when they are prescribing psychotropic medications to seniors.
References
Hien, T., Cumming, R.G., & Cameron, D.et al., (2005). Atypical antipsychotic medicationsand risk of falls in residents of aged care facilities. Journal of the American Geriatrics Society, 53(8), 1290- 1295.
Frels, C., Williams, P., Narayanan, S., & Gariballa, S. (2002). Latrogenic causes of falls in hospitalized elderly patients: a case control study. Postgraduate Medical Journal, 78(922), 487-489.
Landi, F., Onder, G., Cesari, M., Barillaro, C., Russo, A., & Bernabei, R. (2005). Silver Network Home Care Study Group, Psychotropic medications and risk for falls among community-dwelling frail older people: an observational study. Journal of gerontology. Series A: Biological sciences and medical sciences, 60(5), 622- 626.
Lawlor, D. A., Patel, R., & Ebrahim, S. (2003). Association between falls in elderly women and chronic disease and drug use: cross sectional study. British Medical Journal, 327(7417), 712-717.
Passaro, A., Volpato,S., Romagnoni, F., Manzoli,N., Zuliani, G., & Fellin, R. (2000). Benzodiazepines with different half-life and falling in a hospitalized population: the GIFA study. Journal of Clinical Epidemiology, 53(12), 1222-1229.
Rozenfeld, S., Camacho, A., & Veras, P. (2003). Medication as a risk factor for falls in older women in Brazil. Revista Panamericana Salud Publica 13(6), 369- 375.