As an element of her Preventing Falls in the Elderly course for Spring 2005, Eileen Relihan prepared comprehensive information on medications associated with falls. This information is summarised here.

Many falls in the elderly population are iatrogenic and may be avoided by rationalisation of prescribing. Recognised risk factors for falls such as poor walking or gait, confusion and drowsiness, postural hypotension, impaired eyesight and poor thermoregulation can be related to the medications a patient is taking. Most elderly patients are treated with a number of prescribed drugs and the greater the number of medications, the greater their likelihood of falling becomes. Added to this are the age-related changes in pharmacokinetics and pharmacodynamics which predispose the elderly to adverse drug reactions. Specific classes of drugs can also be linked to an increased risk of falling and their usage in elderly patients should be closely monitored.

Psychotropic Agents: Benzodiazepines, antidepressants and antipsychotics
Of all classes of drugs, psychotropic drugs induce the greatest increase in the risk of falling with a 40 to 70 percent increased risk.

Benzodiazepines
• Drowsiness is the most common adverse effect of benzodiazepines. This is often accompanied by ataxia or incoordination.
• A single dose of a benzodiazepine has an effect on balance and can increase the risk of falls. This risk is further increased with regular use and as the dose increases.
• Thus, the lowest risk for falls is associated with a short-acting benzodiazepine, prescribed PRN, at the lowest possible dose and introduced with caution.
* Very short-acting benzodiazepines: Triazolam
* Short-acting benzodiazepines: Temazepam, Lormetazepam, Alprazolam.
* Intermediate-acting benzodiazepines: Lorazepam.
*Long-acting benzodiazepines: Clonazepam, Chlordiazepoxide, Diazepam, Chlorazepate, Flurazepam, Nitrazepam, Flunitrazepam.

Antidepressants
• Antidepressants are the psychotropic agent most commonly associated with falls.
• Tricyclic Antidepressants (TCAs) are associated with a higher risk than Selective Serotonin Reuptake Inhibitors (SSRIs)
• Specifically, TCAs contribute to an increased risk of falling by causing hypotension, blurred vision, motor impairment and constipation.

Antipsychotics
• A number of studies have shown an association between the use of psychotropics and falls, restlessness, wandering and urinary incontinence.
• Use of antipsychotics in nursing homes is frequently inappropriate.
• Use of antipsychotics in dementia may increase the rate of cognitive decline, decrease inhibitions and increase wandering.
• Specifically, antipsychotics predispose to falls by causing hypotension, sedation, anticholinergenic effects and extrpyramidal symptoms.

Antihypertensives and Diuretics
Antihypertensive Agents
• Beta blockers, calcium channel blockers, ACEIs, AIIRAs, alpha adrenoreceptor blockers can all aggravate or cause postural hypotension.
• Lipid-soluble beta blockers can cause confusion and sleep disturbances.
• ACEIs and alpha blockers can cause profound first-dose hypotension.

Diuretics
• All diuretics can cause volume depletion or electrolyte imbalance, thus contributing to instability.

Miscellaneous Agents
Other drugs which can cause adverse effects in the elderly population, making them more susceptible to falling include:

• Antiemitics may cause ataxia and extrapyramidal adverse effects.
• Antiparkinsonian drugs frequently cause postural hypotension.
• NSAIDs may cause confusion and dizziness.
• Antiepileptics may cause unsteadiness and incoordination.
• Coricosteroids may cause mobility problems through muscle wastage and, with prolonged use, may cause osteoporosis.
• Alcohol is a predisposing factor for falls in itself and compounds the risk of falls when taken concurrently with other agents which act on the central nervous system.

Related Articles:
Preventing Falls in the Elderly
Osteoporosis: An Introduction
Medical Management of Osteoporosis
Useful Websites: Osteoporosis and Falls Prevention


Julie Cronin