Drugs and falls

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Drugs and falls
Leicester Medical School

• Simon Conroy
• Senior Lecturer/Geriatrician

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Falls and frailty
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Which drugs?

• Any!
• Specifically drugs
• affecting cognitive function
• reducing cerebral blood flow

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Posturalhypotension

• Sensitive
• Not specific

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Top ten offenders
and some others

• 1.73 psychotropic use
• 1.66 antidepressant use (mainly TCAs)
• 1.59 type Ia antiarrhythmics
• 1.54 sedative/hypnotic use
• 1.50 neuroleptic use
• 1.48 benzodiazepine use
• 1.22 digoxin
• 1.20 ACE inhibitors
• 1.16 centrally acting antihypertensives
• 1.16 NSAID use

• 1.13 nitrates
• 1.12 aspirin
• 1.09 nonnarcotic analgesic use
• 1.08 diuretic
• 1.06 thiazide diuretics
• 0.97 narcotic use
• 0.94 calcium channel blockers
• 0.93 beta-blockers
• 0.90 loop diuretics

Leipzig R, Cumming R, Tinetti M. J Am Geriatr Soc
1999 47(1)30-50.
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The Serotonin story

• Falls and depression are associated share
  common risk factors
• Depression and fracture are associated
• SSRIs increase risk of falling
• SSRIs independently increase risk of fracture
• Exercise good for both??

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Serotonin

• Seven different receptors
• 5HT1-7
• 14 sub-types

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SSRIs evidence for benefitin depressed older
people

• The subgroups of TCAs (classical and related
  TCAs) are compared in terms of side effect
  ratios no real differences
• ?TCA related antidepressants might offer a
  relatively low side effect profile may be
  associated with better tolerability
• Withdrawal rate of TCA related antidepressants
  appears similar to that of SSRIs
• May offer an acceptable alternative in those
  situations in which SSRIs are not acceptable

• Difficulties in generalising results from trials
  into the general population
• Findings suggest that SSRIs and TCAs are of
  equal efficacy
• Older patients receiving TCA related
  antidepressants have a similar withdrawal rate
  compared to SSRIs
• When all TCAs and classical TCAs trials are
  analysed significantly higher withdrawal rates
  than those receiving SSRIs

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Can drugs be used to prevent falls?

• Vitamin D reduces falls rates by 201
• Probably only if vitamin D deficient2
• Any others?
• Water
• (TEDS
• Fludrocortisone
• Midodrine)

• Bischoff-Ferrari HA, Dawson-Hughes B, Willett WC,
  et al. Effect of Vitamin D on falls a
  meta-analysis.see comment. JAMA
  2004291(16)1999-2006.
• Gillespie LD, Robertson MC, Gillespie WJ, et al.
  Interventions for preventing falls in older
  people living in the community John Wiley
  Sons, Ltd, 2009.

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A practical approach to medication reviews
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STOPP/START
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STOPP/START audit

• n74
• 81 years old, 4 comorbidities, 50 with geriatric
  syndromes

• Admission
• 6.8 medications per patient
• 73 taking 4 medications
• STOPP
• 46 patients had at least one inappropriate drug
  (GS 27)
• 13 individual drug items were inappropriate (GS
  3)
• START
• 30 (GS 15)

• Discharge
• 6.3 medications per patient
• 84 taking 4 medications
• STOPP
• 49 patients had at least one inappropriate drug
  (GS 27)
• 5 individual drug items were inappropriate (GS
  3)
• mean difference 0.86, plt0.0001
• START
• 30 (GS 15)

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Summary

• Drugs are an important cause of falls
• Evidence base for prescribing in older people is
  poor
• Rationale approach to prescribing required
• STOPP/START