These Medicines Should Be Reviewed Regularly to Prevent Falls

Polypharmacy can compromise an elderly's safety
Polypharmacy can compromise an elderly’s safety

Old age is often accompanied by multiple medical conditions. We may have to consult different specialists and be prescribed different kinds of medication. In addition, we may be buying over-the-counter drugs or herbs for ailments such as allergies or sea sickness.

According to a research study by Karolinska Institutet in Stockholm, Sweden1, half of the 20 most frequently prescribed medications to elderly may increase fall risk. The most significant risk involves the use of opioids and antidepressants, but hypnotics, sedatives, and analgesics were also of concern.

The US Centers for Disease Control (CDC) recommends people aged 65+ to request a medication review with their doctors. The purpose of the review is to identify problem medications and weigh the benefits against risks. And to reduce, or even eliminate, these medications if deemed unnecessary.

The three categories of medicines which are likely to increase fall risk are outlined below. Obviously, it is an incomplete list. It is only meant to make you aware of the problem. We hope the references supplied at the end will make up the deficit.

Only the generic names of these drugs are used to avoid confusion.

Medicines That Affect Brain Functions

Any sedative, tranquilizer, or sleep medication will affect normal brain functions. They tend to cause drowsiness. Common examples include zolpidem for sleep, or lorazepam for anxiety. Antipsychotic medications used for restless dementia behaviours, such as risperidone or quetiapine, can also increase sedation and fall risk.

These drugs can also cause or worsen confusion, especially in people with memory problems or Alzheimer’s disease.

  1. Benzodiazepines. This class of medicines is usually prescribed to treat anxiety, panic attacks, sleep problems and other disorders. Examples include diazepam, lorazepam, chlordiazepoxide, oxazepam, temazepam, nitrazepam, loprazolam, lormetazepam, clobazam and clonazepam.

Benzodiazepines affect how brain cells transmit messages. Decreasing the excitability of brain cells has a calming effect on the nervous system.

They medicines are addictive and have been associated with developing dementia. Research studies consistently found that benzodiazepines are associated with increased fall risk.

Stopping benzodiazepines abruptly is dangerous. These drugs should always be weaned off under medical supervision.

  1. Non-benzodiazepine prescription sedatives. These medicines are usually prescribed for sleep problems. The most well-known are the “Z-drugs”- zolpidem, zaleplon (not available in UK), and eszopiclone.

Z-drugs’ action on the brain cells are similar to benzodiazepines. They too have similar long-term usage problems as benzodiazepines. They have been shown to impair balance and thinking in clinical studies.

  1. Antipsychotics. These are psychiatric medicines licenced to treat mental health problems with psychosis symptoms, as in schizophrenia and bipolar disorder. Sometimes they are prescribed to treat severe depression. They have been used to control agitation and psychotic experiences in Alzheimer’s and other dementias.

There are two main types of antipsychotics:

  • Typical antipsychotics – first generation of antipsychotics developed in the 1950s. Examples are: chlorpromazine, haloperidol.
  • Atypical antipsychotics – second-generation antipsychotics developed in the 1990s. These include risperidone, quetiapine, olanzapine, and aripiprazole.

The side effects of all antipsychotics include drowsiness and blurred vision, and are associated with increased falls in clinical studies.

  1. Anticonvulsants. This is a diverse group of medicines which are commonly known as antiepileptic or anti-seizure drugs. Common ones are: sodium valproate, carbamazepine, lamotrigine, levetiracetam, oxcarbazepine, ethosuximide, and topiramate.

Apart from seizures, some of these medicines can be used to treat other conditions. For example, Gabapentin is often used to treat nerve pain. Valproic acid is used to stabilize moods in conditions such as bipolar disorder, as well as to treat difficult behaviours in Alzheimer’s and other dementias.

Clinical research suggests that anticonvulsants are associated with increased fall risk. They are also found to have many other problematic side-effects including drowsiness.

  1. Antidepressants. These are medications used to treat clinical depression or to prevent it recurring. They can also be used to treat obsessive compulsive disorder, generalized anxiety disorder and post-traumatic stress disorder. Sometimes they are used to treat chronic pain.

There are different types of antidepressants. The most common ones are:

  • Selective serotonin reuptake inhibitors (SSRIs) – e.g. sertraline, citalopram, escitalopram, paroxetine, and fluoxetine.
  • Serotonin-noradrenaline reuptake inhibitors (SNRIs) – e.g. duloxetine, venlafaxine.
  • Noradrenaline and specific serotonergic antidepressants (NASSAs) – e.g. mirtazapine
  • Tricyclic antidepressants (TCAs) – e.g. amitriptyline, nortriptyline. Nowadays used for nerve pain rather than depression.

Virtually all antidepressants have been associated with increased fall risk.

  1. Opioid analgesics. Opioid or narcotic analgesics are mainly used for the treatment of moderate to severe pain. Opioids often cause drowsiness, as well as other side-effects.

Commonly used opioids include codeine, hydrocodone, oxycodone, morphine, fentanyl, and methadone.

The results of clinical research on the association between opioids and fall risk in elderly is mixed. However, some experts, including the CDC, still recommend that narcotic use be evaluated as part of fall risk management.

  1. Anticholinergics. These medicines block the neurotransmitter acetylcholine in the central and peripheral nervous systems. A wide variety of medicines have anticholinergic property. Many of them are over-the-counter drugs that seniors take for problems such as allergies, overactive bladder, vertigo, and nausea. Certain types of antidepressants prescribed for nerve pain also has anticholinergic action.

They include:

  • Antihistamines with sedative effect such as diphenhydramine. Non-sedating antihistamines such as loratadine are less anticholinergic and are safer for the brain.
  • Over-the-counter analgesics, e.g. acetaminophen (paracetamol) and ibuprofen, are sold with sedating ingredients added for night time use. Some night-time cold and cough medications also contain sedative.
  • Medicines for overactive bladder, e.g. oxybutynin and tolterodine.
  • Medicines for vertigo, motion sickness, or nausea. For example, meclizine, scopolamine, or promethazine.
  • Medicines for itching or hives, e.g. hydroxyzine and diphenhydramine.
  • Muscle relaxants such as cyclobenzaprine are often prescribed for back or neck pain.
  • Medicines for nerve pain. Commonly used are tricyclic antidepressants such as amitriptyline and nortriptyline.

Anticholinergics often cause drowsiness and clouded thinking. They have been associated with developing dementia.

Clinical research on the association of anticholinergics and fall risk has shown mixed results. However, since anticholinergics can cause drowsiness and are risky for seniors for other reasons, many experts believe it is reasonable to include them when reviewing medications for fall prevention.

Medications That Affect Blood Pressure

When you stand up suddenly from a lying or sitting position, you may experience drop in blood pressure which makes you dizzy or lightheaded. This is called postural or orthostatic hypotension. Most medications for high blood pressure can cause or worsen postural hypotension.

Antihypertensives

These are prescription medications used to treat high blood pressure. There are many classes of antihypetensives and each class include a number of different drugs. We will just list the common ones here.

  • Diuretics. Diuretics make you pass more urine to remove excess water and sodium from your body. This will reduce the fluid tension in the blood vessels and lower the blood pressure. There are three types of diuretics: thiazide, loop, and potassium-sparing. Each type affects a different part of the kidneys and may have different uses, side effects and precautions.
  1. Thiazide diuretics – e.g. indapamide, chlorothiazide and bendroflumethiazide.
  2. Potassium-sparing diuretics – e.g. amiloride and spironolactone.
  3. Loop diuretic – e.g. furosemide, bumetanide.

If diuretics are not enough to control your blood pressure, your doctor may add other antihypertensives medications to your treatment.

  • Angiotensin-converting enzyme (ACE) inhibitors. They relax blood vessels by preventing the formation of angiotensin which constricts blood vessels. Frequently prescribed ACE inhibitors include enalapril, lisinopril, perindopril and Ramipril.
  • Angiotensin-2 receptor blockers (ARBs). They relax blood vessels by blocking the action of angiotensin. This class includes candesartan, irbesartan, losartan, valsartan and olmesartan.
  • Calcium channel blockers. They cause the smooth muscles of the heart and arteries to relax by preventing calcium from entering the cells. Frequently prescribed calcium channel blockers include amlodipine, diltiazem, nifedipine, felodipine and verapamil.
  • Beta blockers. These medicines work by blocking the effects of epinephrine, also known as adrenaline. As a result, the heart beats slower and with less force, and the blood pressure is lower. Frequently prescribed beta blockers include atenolol, bisoprolol, metoprolol, and nadolol.
  • Renin inhibitors. These medicines prevent the kidneys from producing renin – an enzyme which starts a chain-reactions resulting in high blood pressure. An example of renin inhibitor is aliskiren.

Some medicines used for improving urine flow in older men with prostatic problem belong to a class of drugs known as alpha-blockers. They work by blocking the action of norepinephrine (noradrenaline) on small arteries and veins. The effects are better blood flow and lower blood pressure.

Hence, people who are on prostate medications such as tamsulosin, terazosin, doxazosin, and prazosin should watch out for postural hypotension too.

Clinical evidence on the association of antihypertensives with fall risk could not be confirmed. Despite that, evaluation of blood pressure medications in older adults at high risk for falls is recommended.

Medications That Lower Blood Sugar

It is estimated that about 25% of people over age 65 are diabetes. Both type 1 diabetes and type 2 diabetes need medications to help keep blood sugar levels normal.  Research studies have found that people with diabetes have a higher risk of falls compared to others of the same age. It is because most diabetes medications can cause or worsen hypoglycaemia (low blood sugar).

Type 1 diabetes require insulin therapy. Type 2 diabetes are usually on oral medications, although in some cases insulin may be prescribed in conjunction.

Metformin is usually the first choice for type 2 diabetes because the risk of hypoglycaemia is minimal.

What to Do if You or Your Relative Is on These Medications

So, are you using any of the medication mentioned above?

Now, even though most of these medicines are associated with increased fall risk, it doesn’t mean they should be forbidden. What we need is a careful assessment of your present condition and weigh the benefits and risks of taking the medicines. And the medication review must only be conducted by a medical doctor and you.

Before you request a medication review, take a good look at ALL your medications – both prescription medicines and over-the-counter medicines including herbal products. And ask:

  • Why am I taking this medicine? What problem is it meant to treat or manage?
  • How necessary is this medication? Can I discontinue it? Can I take a lower dosage? Is non-drug-therapy available for my problem?
  • Could there be interactions between these medicines?
  • Do I sometimes feel dizzy or lightheaded? Am I in fear of falling? Do these symptoms appear or worsen after I have taken this medicine?

You may want to learn more and do some research on those medications that you are worried about.

Conclusion

Any medication that causes drowsiness, dizziness, vision problems, loss of balance and hypotension could potentially increase the chances of falling.

The CDC’s guidance to healthcare providers on medications linked to falls is:

STOP medications when possible.

SWITCH to safer alternatives.

REDUCE medications to the lowest effective dose.2

The Royal College of Physicians had also issued a guidance sheet on medicines and falls.3

We hope you and your doctors could regularly evaluate your need and dosage of these medications. Then you would be in a much better position in the overall fall prevention plan.

 

 

References:

  1. Kuschel B M, Laflamme L, Möller J. (2015) “The Risk of Fall Injury in Relation to Commonly Prescribed Medications Among Older People–A Swedish Case-Control Study”. Eur J Public Health. 2015 Jun;25(3):527-32.
  2. CDC’s flyer – Medications Linked to Falls. https://www.cdc.gov/steadi/pdf/STEADI_Medication_Linked_to_Falls-a.pdf
  3. Royal College of Physicians: Guidance sheet – Medicines and Falls in Hospital. https://www.rcplondon.ac.uk/file/933/download?token=drzlaAJ2
  4. 2015 American Geriatrics Society Updated Beers Criteria: Medications that Older Adults Should Avoid or Use with Caution.
  5. Kernisan, L. https://betterhealthwhileaging.net/preventing-falls-10-types-of-medications-to-review
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