Antidepressants and falls among elderly people in long-term care

Mapping sex and gender differences in falls among older adults: A scoping review

BACKGROUND

There is growing recognition of the importance of sex and gender differences within falls literature, but the characterization of such literature is uncertain. The aim of this scoping review was to (1) map the nature and extent of falls literature examining sex or gender differences among older adults, and (2) identify gaps and opportunities for further research and practice.

METHODS

We used a scoping review methodology. Eligible studies included participants with a mean age of ≥ 60 years and study aims specifying falls and either sex or gender concepts. MEDLINE, Embase, CINAHL, Ageline, and Psychinfo databases were searched from inception to March 2, 2022. Records were screened and charted by six independent reviewers. Descriptive and narrative reports were generated.

RESULTS

A total of 15,266 records were screened and 74 studies were included. Most studies reported on sex and gender differences in fall risk factors (n = 52, 70%), incidence/prevalence (n = 26, 35%), fall consequences (n = 22, 30%), and fall characteristics (n = 15, 20%). The majority of studies (n = 70, 95%) found significant sex or gender differences in relation to falls, with 39 (53%) identifying significant sex differences and 31 (42%) identifying significant gender differences. However, only three (4%) studies defined sex or gender concepts and only nine (12%) studies used sex or gender terms appropriately. Fifty-six (76%) studies had more female participants than males. Four (5%) were intervention studies. Studies did not report falls in line with guidelines nor use common fall definitions.

CONCLUSION

Sex and gender differences are commonly reported in falls literature. It is critical for future research to use sex and gender terms appropriately and include similar sample sizes across all genders and sexes. In addition, there is a need to examine more gender-diverse populations and to develop interventions to prevent falls that address sex and gender differences among older adults.

Multinational Investigation of Fracture Risk with Antidepressant Use by Class, Drug, and Indication

OBJECTIVES

Antidepressants increase the risk of falls and fracture in older adults. However, risk estimates vary considerably even in comparable populations, limiting the usefulness of current evidence for clinical decision making. Our aim was to apply a common protocol to cohorts of older antidepressant users in multiple jurisdictions to estimate fracture risk associated with different antidepressant classes, drugs, doses, and potential treatment indications.

DESIGN

Retrospective (2009-2014) cohort study.

SETTING

Five jurisdictions in the United States, Canada, United Kingdom, and Taiwan.

PARTICIPANTS

Older antidepressant users-subjects were followed from first antidepressant prescription or dispensation to first fracture or until the end of follow-up.

MEASUREMENTS

The risk of fractures with antidepressants was estimated by multivariable Cox proportional hazards models using time-varying measures of antidepressant dose and use vs nonuse, adjusting for patient characteristics.

RESULTS

Between 42.9% and 55.6% of study cohorts were 75 years and older, and 29.3% to 45.4% were men. Selective serotonin reuptake inhibitors (SSRIs) (48.4%-60.0%) were the predominant class used in North America compared with tricyclic antidepressants (TCAs) in the United Kingdom and Taiwan (49.6%-53.6%). Fracture rates varied from 37.67 to 107.18 per 1,000. The SSRIs citalopram (hazard ratio [HR] = 1.23; 95% confidence interval [CI] = 1.11-1.36 to HR = 1.43; 95% CI = 1.11-1.84) and sertraline (HR = 1.36; 95% CI = 1.10-1.68), the SNRI duloxetine (HR = 1.41; 95% CI = 1.06-1.88), TCAs doxepin (HR = 1.36; 95% CI = 1.00-1.86) and imipramine (HR = 1.16; 95% CI = 1.05-1.28), and atypicals (HR = 1.34; 95% CI = 1.14-1.58) increased fracture risk in some but not all jurisdictions. In the United States and the United Kingdom, fracture risk with all classes was higher when prescribed for depression than chronic pain, a trend that is likely explained by drug choice.

CONCLUSION

The fracture risk for patients may be reduced by selecting paroxetine, an SSRI with lower risk than citalopram, the SNRI venlafaxine over duloxetine, and the TCA amitriptyline over imipramine or doxepin. There is uncertainty about the risk associated with the atypical antidepressants. J Am Geriatr Soc 68:1494-1503, 2020.

Falls and risk factors of falls for urban and rural community-dwelling older adults in China

BACKGROUND

Falls among older people have become a public health concern due to serious health consequences. Despite abundant literature on falls in older people, little is known about the rural-urban differentials in falls among older people in China. This research fills the voids of prior literature by investigating falls and the associated risk factors among Chinese seniors, with a particular focus on the rural-urban differences.

METHODS

Data are from the 2010 wave of Chinese Longitudinal Survey on Urban and Rural Elderly. The analysis includes 16,393 respondents aged 65 and over, with 8440 and 7953 of them living in urban and rural areas, respectively. Descriptive analyses are performed to examine incidence, locations, circumstances and consequences of falls in older people. Regression analysis is used to investigate the effects of risk factors on falls among older people in urban and rural China.

RESULTS

The incidence of falls is higher among rural than urban older people. In both settings, older people are more likely to fell outside of home. But common outdoor falls among rural and urban older people differ in terms of locations and circumstances. Urban older people are more likely to report falling on the road whereas their rural counterparts have experienced more falls in the yard. Falls occurring within homes or immediate home surroundings are also common; but few falls occurred in public areas. The rate of hospitalization of urban seniors after falling is higher than that of rural ones. Most risk factors of falls show similar than different effects on rural and urban elders' risks of falling.

CONCLUSIONS

Incidence, locations, circumstances and consequences of falls vary among Chinese rural and urban older people. But most risk factors for falls show similar effects on rural and urban elders' odds of falling. Implications drawn from this research provide suggestions for the government and local agencies to develop suitable fall prevention strategies which may well be applicable to other countries.

The Association Between Depression and Traumatic Brain Injury in Older Adults: A Nested Matched Case Control Study

Objective: Determine association between depression and traumatic brain injury (TBI) in the older adult home care population of Ontario, Canada (2003-2013). Method: A nested matched case control study was used, and data were retrieved for service users 65 years or older who received home care between 2003 and 2013. Incident TBI cases were matched to four controls by sex, age, and assessment date. Odds ratios and multivariable conditional logistic regression were completed. Results: 554,313 service users were included of which 5,215 (0.9%) had a TBI and 39,048 (7.0%) had depression. Fall history was an effect modifier. The association between depression and TBI was 1.10 (95% confidence interval [CI] = [0.93, 1.31]) for those without a history of falling, while for those with a history of falling it was 1.24 (95% CI = [1.03, 1.48]) after adjusting for education and Alzheimer’s disease. Discussion: Depression is associated with sustaining a TBI in those with a history of falling.

Characteristics and Incidence of Traumatic Brain Injury in Older Adults Using Home Care in Ontario from 2003-2013

Objectives

Describe the characteristics and determine the annual cumulative incidence of traumatic brain injury (TBI) in older adults receiving home care in Ontario from 2003 to 2013.

Methods

A retrospective cohort study of longitudinal data from the Ontario Association of Community Care Access Centers (N = 554,313). TBI, demographic variables, depression, neurological conditions, and recent falls were measured from the Resident Assessment Instrument–Home Care. Comparisons were made between service users with and without TBI using odds ratios. Standardized incidence rates were calculated and the 10-year trend of annual cumulative incidence rates was examined.

Results

Characteristics associated with TBI: male sex (OR: 1.54), aboriginal origin (OR: 1.98), increasing age (low of OR: 1.22, in 70–74 years; high of OR: 2.31, in 90 years and older; comparison 65–69 years), being widowed (OR: 1.59), having one or more falls (OR: 2.31), the use of antidepressants (OR: 1.49) and the presence of depression (OR: 1.57), dementia (OR: 1.65), hemiplegia (OR: 4.34), multiple sclerosis (OR: 3.19) or parkinsonism (OR: 1.22). TBI incidence was significantly higher than rates previously reported in the literature. There was no change in the overall annual cumulative incidence over the 10-year period (p = .13).

Conclusions

Certain demographic characteristics, neurological diseases, antidepressant use, and a recent fall are associated with TBI. Incidence of TBI is higher than previous estimates and the overall incidence is not changing over time. These results can be used to improve care of the elderly and to generate hypotheses for future research regarding TBI in the home care setting.

Effectiveness of bright light therapy on depressive symptoms in older adults with non-seasonal depression: a systematic review protocol

REVIEW QUESTION

What is the effectiveness of bright light therapy (BLT) on depressive symptoms in older adults with non-seasonal depression?

REVIEW OBJECTIVE

The review objective is to determine the current evidence related to the effectiveness of BLT on depressive symptoms in older adults with non-seasonal depression.

Sex- and endocrine-stage-differences in middle-aged rats in an animal model of OCD

Various clinical studies suggest that many features of OCD are influenced by sex, age and fluctuations in hormonal levels. Animal models have confirmed these differences, and suggest they are mediated by the serotonergic system. We compared the perseveration behavior in a T-maze after the administration of the 5-HT1A agonist, 8-OH-DPAT (2.0 mg/kg) and the preventive action of subchronic fluoxetine (10 mg/kg, 3 times) in middle-aged (11-14 months) males and female rats in two endocrine states: irregular cycles (tested in diestrus) or persistent diestrus. After 8-OH-DPAT, females with persistent diestrus presented higher perseveration scores than males and females with irregular cycles. Fluoxetine produced an anticompulsive-like effect only in females with persistent diestrus. Females in persistent diestrus showed higher estradiol levels than those in irregular cycles or males. In all groups 8-OH-DPAT increased ambulation and fluoxetine did not modify this action. In males, the combined administration of fluoxetine and 8-OH-DPAT impaired motor coordination. Data are discussed on the basis of estradiol levels and sex differences.

Risk factors for falls in older people in nursing homes and hospitals. A systematic review and meta-analysis

This is a systematic review and meta-analysis aimed at providing a comprehensive and quantitative review of risk factors for falls in older people in nursing homes and hospitals. Using MEDLINE, we searched for prospective studies investigating risk factors for falls in nursing home residents (NHR) and older hospital inpatients (HI). When there were at least 3 studies investigating a factor in a comparable way in a specific setting, we computed the pooled odds ratio (OR) using random effect models. Twenty-four studies met the inclusion criteria. Eighteen risk factors for NHR and six for HI were considered, including socio-demographic, mobility, sensory, medical factors, and medication use. For NHR, the strongest associations were with history of falls (OR=3.06), walking aid use (OR=2.08) and moderate disability (OR=2.08). For HI, the strongest association was found for history of falls (OR=2.85). No association emerged with age in NHR (OR=1.00), while the OR for a 5years increase in age of HI was 1.04. Female sex was, if anything, associated with a decreased risk. A few other medical conditions and medications were also associated with a moderately increased risk. For some important factors (e.g. balance and muscle weakness), a summary estimate was not computed because the measures used in various studies were not comparable. Falls in older people in nursing homes and hospitals have multifactorial etiology. History of falls, use of walking aids and disability are strong predictors of future falls.

Relationship between use of antidepressants and risk of fractures: a meta-analysis

It has been shown that antidepressants would have a direct action on bone metabolism and would be associated with increased fracture risk. Results from this large meta-analysis show that both SSRIs and TCAs are associated with a moderate and clinically significant increase in the risk of fractures of all types.

INTRODUCTION

This study seeks to investigate the relationship between use of antidepressants and the risk of fracture.

METHODS

An exhaustive systematic research of case-control and cohort studies published or performed between 1966 and April 2011 that reported risk estimates of fracture associated with use of antidepressants was performed using MEDLINE, PsycINFO, and the Cochrane Systematic Review Database, manual review of the literature, and congressional abstracts. Inclusion, quality scoring, and data abstraction were performed systematically by three independent reviewers.

RESULTS

A total of 34 studies (n = 1,217,464 individuals) were identified. Compared with non-users, the random effects pooled RR of fractures of all types, among antidepressant users, were 1.39 (95%CI 1.32-1.47). Use of antidepressants were associated with a 42 %, 47 %, and 38 % risk increase in non-vertebral, hip, and spine fractures, respectively ([For non-vertebral fractures: RR = 1.42, 95%CI 1.34-1.51]; [For hip fractures: RR = 1.47, 95%CI 1.36-1.58]; [For spine fractures: RR = 1.38, 95%CI 1.19-1.61]). Studies examining SSRI use showed systematically a higher increase in the risk of fractures of all types, non-vertebral, and hip fractures than studies evaluating TCA use.

CONCLUSIONS

Results from this large meta-analysis show that both SSRIs and TCAs are associated with a moderate and clinically significant increase in the risk of fractures of all types.

Outcomes of polypharmacy in nursing home residents

This article provides a comprehensive review of the outcomes of polypharmacy in nursing homes. Our review had some limitations. First, we only included studies beginning in 1990, and significant earlier studies are not included. Only English language articles were included. We only researched studies from MEDLINE, and may have missed studies based on our search terms and search tools. There are many definitions of polypharmacy in the literature, including number of medications or inappropriate medications. In this review, we defined polypharmacy as a high number of medications, but not inappropriate medications. It was not surprising that polypharmacy was consistently associated with an increased number of potentially inappropriate drugs. The majority of studies were viewed showed that polypharmacy was associated with increased ADEs, increased DDIs, and increased hospitalizations. We were surprised that polypharmacy was not consistently linked with falls, fractures, and mortality. For the mortality studies, it has been postulated that perhaps some patients receiving 10 or more medications may have been moribund or receiving end-of-life or hospice care. It is possible that the number of medications is not as important as the number of potentially in appropriate drugs. There need to be more studies on these outcomes, using different definitions of polypharmacy. Polypharmacy was associated with increased costs. The drug-related morbidity and mortality, including those resulting from inappropriate medications and increased staff time, led to increased costs. Use of consultant pharmacists has been shown to decrease polypharmacy costs.

Prevalence and predictors of antidepressant prescribing in nursing home residents in the United States

BACKGROUND

Late-life depression is a common psychiatric disorder associated with increased morbidity and mortality. Depression is often under-detected and undertreated in elderly nursing home residents.

OBJECTIVES

The aim of this study was to examine the prevalence of antidepressant drug use and to identify the factors associated with its use among elderly nursing home residents.

METHODS

The study involved the analysis of a nationally representative sample of prescription and resident files from the 2004 National Nursing Home Survey (NNHS). The study sample included all elderly nursing home residents ≥65 years of age. The analysis focused on prescribing from any antidepressant class, including selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), serotonin modulators, serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), and others. Descriptive weighted analysis was performed to examine antidepressant use prevalence patterns in elderly nursing home residents. Multiple logistic regression analysis within the conceptual framework of Anderson's behavioral model was used to examine the predisposing, enabling, and need characteristics associated with antidepressant use.

RESULTS

According to the 2004 NNHS, overall prevalence of antidepressant use among elderly nursing home residents was 46.22% (95% CI, 45.16-47.27). Most antidepressant users were ≥85 years of age (49.7%), female (75.7%), non-Hispanic (96.4%), and white (91.1%). The most prescribed class of antidepressants was SSRIs (31.09%; 95% CI, 30.12-32.07), followed by serotonin modulators (4.65%; 95% CI, 4.22-5.09), SNRIs (2.78%; 95% CI, 2.45-3.12), TCAs (2.34%; 95% CI, 2.03-2.65), and MAOIs (0.01%; 95% CI, 0.00-0.03). Citalopram (12.92%; 95% CI, 12.21-13.63) was the most prescribed individual antidepressant, followed by mirtazapine (10.19%; 95% CI, 9.55-10.84). Among the predisposing characteristics, age, race, and marital status were significantly associated with antidepressant use. The odds of receiving an antidepressant were lower for those aged ≥85 years and those who were unmarried elderly residents, when compared with their counterparts; whites were more likely to receive an antidepressant than nonwhites. Enabling factors such as Medicaid and bed capacity significantly predicted antidepressant use. Having Medicaid was positively associated with antidepressant prescription, whereas an increase in the total number of beds decreased the probability of an antidepressant prescription. Among need characteristics, the likelihood of antidepressant prescription use decreased with increased dependence in decision-making ability and out-of-bed mobility. The presence of depressed mood indicators and a history of falls/fractures increased the likelihood of antidepressant prescription use. The odds of receiving an antidepressant increased with diagnosis of depression but decreased with diagnosis of anxiety.

CONCLUSION

Nearly half of elderly nursing home residents received antidepressants. In addition to need factors, predisposing and enabling factors played an important role in influencing the use of antidepressants in elderly nursing home residents.

Use of antidepressant medications and risk of fracture in older women

Use of antidepressant medications has been associated with increased risk of fracture, but prior studies have been limited by incomplete control of confounders or a limited number of fractures. Use of antidepressant medications by 8,217 community-dwelling women aged 69 and older from a population-based prospective cohort study at four US clinical centers was assessed by interview at four examinations over a 10-year period, beginning in 1992-1994. Use was coded as a time-dependent variable. Incident fractures occurring after the initial medication assessment until July 2007 were confirmed by radiographic reports. Potential confounders were included in multivariable models and updated at each follow-up visit. Compared to nonusers of antidepressant medications, women using SSRIs experienced a higher risk of nonspine fracture in age-adjusted models (HR = 1.36, 95% CI 1.11-1.67) and in multivariable models controlling for potential confounders (HR = 1.30, 95% CI 1.04-1.62). SSRI use was not associated with an increased risk of first hip fracture (HR = 1.01, 95% CI 0.71-1.44) but was associated with an increased risk of wrist fracture (HR = 1.54, 95% CI 1.01-2.36). TCA use was associated with an increased risk of nonspine fracture in age-adjusted models, but in multivariable models this risk was attenuated. SSRI use was associated with a higher risk of any nonspine fracture, but not hip fracture, in this cohort of older women. TCA use was associated with a higher risk of nonspine fracture, but this association was in part explained by confounding factors.

Medication use as a risk factor for inpatient falls in an acute care hospital: a case-crossover study

AIMS

The present study aimed to evaluate the associations between medication use and falls and to identify high risk medications that acted as a trigger for the onset of falls in an acute care hospital setting.

METHODS

We applied a case-crossover design wherein cases served as their own controls and comparisons were made within each participant. The 3-day period (days 0 to -2) and the 3-day periods (days -6 to -8, days -9 to -11 and days -12 to -14) before the fall event were defined as the case period and the control periods, respectively. Exposures to medications were compared between the case and control periods. Odds ratios (OR) and 95% confidence intervals (CI) for the onset of falls with respect to medication use were computed using conditional logistic regression analyses.

RESULTS

A total of 349 inpatients who fell during their hospitalization were recorded on incident report forms between March 2003 and August 2005. The initial use of antihypertensive, antiparkinsonian, anti-anxiety and hypnotic agents as medication classes was significantly associated with an increased risk of falls, and these ORs (95% CI) were 8.42 (3.12, 22.72), 4.18 (1.75, 10.02), 3.25 (1.62, 6.50) and 2.44 (1.32, 4.51), respectively. The initial use of candesartan, etizolam, biperiden and zopiclone was also identified as a potential risk factor for falls.

CONCLUSIONS

Medical professionals should be aware of the possibility that starting a new medication such as an antihypertensive agent, including candesartan, and antiparkinsonian, anti-anxiety and hypnotic agents, may act as a trigger for the onset of a fall.

Psychotropic Drugs and Falls in the Elderly People: Updated Literature Review and Meta-Analysis

Objective: To carry out meta-analyses on psychotropic drugs and to provide an update of the risk of falling in the elderly people related to psychotropic drugs. Design: Meta-analyses of studies on psychotropic drugs. Results: 177 studies are included, of which 71 have data on risk factors associated with psychotropic drugs. The odds ratio and 95% Cl for associations between use of psychotropic drugs and fall are 1.78 and 1.57-2.01, respectively. This result is statistically heterogeneous. This heterogeneity disappears in the group of very old participants for each class. Conclusion: Our study confirms the association between falls in the elderly people and psychotropic drugs. These results are similar to those of former meta-analyses but with different methods. It shows that these meta-analyses on psychotropic drugs have a small impact on prescribing habits. They only give evidence to support the association between psychotropic drugs and falls even if there is no proven link.

Episodes of falling among elderly people: a systematic review and meta-analysis of social and demographic pre-disposing characteristics

CONTEXT

The multifactorial nature of falls among elderly people is well-known. Identifying the social-demographic characteristics of elderly people who fall would enable us to define the typical profile of the elderly who are at risk of falling.

OBJECTIVE

We aimed to isolate studies in which the social-demographic risk factors for falls among the elderly have been evaluated and to carry out a meta-analysis by combining the results of all of these selected studies.

METHOD

We did a systematic literature review using the key words "accidental fall / numerical data" and "risk factors." Inclusion criteria entailed the selection of articles with the following characteristics: population of subjects aged 60 years or over, falls that took place in everyday life, and social-demographic risk factors for falls.

RESULTS

3,747 indexed articles published between 1981 and 2007 were identified, and 177 studies with available data were included, of which 129 had data on social-demographic risk factors for falls. Difficulties in activities of daily living (ADL) or in instrumental activities of daily living (IADL) double the risk of falling: The OR and 95% Cl were 2.26 (2.09, 2.45) for disturbance ADL and 2.10 (1.68, 2.64) for IADL. The OR and 95% Cl for Caucasians were 1.68 (0.98 - 2.88) and 0.64 (0.51 - 0.80) for Hispanics. In the subgroup of patients older than eighty, being married protected people from falling with an OR and 95% Cl =0.68 (0.53 - 0.87).

CONCLUSION

Defining factors that create a risk of falling and protect elderly people from falls using social-demographic characteristics lets us focus on an "at risk" population for which a specific program could be developed.

Fall-related injuries in a nursing home setting: is polypharmacy a risk factor?

Background

Polypharmacy is regarded as an important risk factor for fallingand several studies and meta-analyses have shown an increased fall risk in users of diuretics, type 1a antiarrhythmics, digoxin and psychotropic agents. In particular, recent evidence has shown that fall risk is associated with the use of polypharmacy regimens that include at least one established fall risk-increasing drug, rather than with polypharmacy per se. We studied the role of polypharmacy and the role of well-known fall risk-increasing drugs on the incidence of injurious falls.

Methods

A retrospective observational study was carried out in a population of elderly nursing home residents. An unmatched, post-stratification design for age class, gender and length of stay was adopted. In all, 695 falls were recorded in 293 residents.

Results

221 residents (75.4%) were female and 72 (24.6%) male, and 133 (45.4%) were recurrent fallers. 152 residents sustained no injuries when they fell, whereas injuries were sustained by 141: minor in 95 (67.4%) and major in 46 (32.6%). Only fall dynamics (p = 0.013) and drugs interaction between antiarrhythmic or antiparkinson class and polypharmacy regimen (≥7 medications) seem to represent a risk association for injuries (p = 0.024; OR = 4.4; CI 95% 1.21 - 15.36).

Conclusion

This work reinforces the importance of routine medication reviews, especially in residents exposed to polypharmacy regimens that include antiarrhythmics or antiparkinson drugs, in order to reduce the risk of fall-related injuries during nursing home stays.

[Falls risk factors of inpatients]

PURPOSE

The purpose of this study was to identify the risk factors for falls and to suggest data for developing a program for preventing falls.

METHODS

This was a case-control study in five university hospitals and a general hospital. In total, 216 patients over the age of 18 yr admitted from January 1 to December 31, 2007 participated. One hundred eight patients with experience of falling were matched by gender, age level, diagnosis, and length of stay with 108 patents with no experience of falling admitted on the same unit. A quality assurance coordinator nurse in each hospital examined 35 fall risk factors developed by researchers.

RESULTS

In acute hospitals, history of falls, orientation ability, dizziness or vertigo, general weakness, urination problems, transfer/mobility difficulty, walking dependency, impatience, benzodiazepines, diuretics, and vasodilators showed significance on adjusted-odds ratios for fall. Logistic regression analysis was performed to elucidate the factors that influence falls. The probability of falls was increased by dizziness/vertigo, general weakness, and impatience/agitation.

CONCLUSION

This finding can be used as a useful resource in developing nursing intervention programs to predict and prevent the falls of inpatients.

The influence of drug use on fall incidents among nursing home residents: a systematic review

BACKGROUND

Falls are a major health problem among the elderly, particularly in nursing homes. Abnormalities of balance and gait, psychoactive drug use, and dementia have been shown to contribute to fall risk.

METHODS

We conducted a systematic review of the literature to investigate which psychoactive drugs increase fall risk and what is known about the influence of these drugs on gait in nursing home residents with dementia. We included studies with a prospective cohort design on psychoactive drug use in nursing homes with dementia residents and with falls as an outcome measure.

RESULTS

Seventeen studies were included in the review. Pooled risk estimates were not calculated because there was no homogeneity across studies. We assessed the strength of evidence for psychoactive drugs as a prognostic factor for falls by defining four levels of evidence: strong, moderate, limited or inconclusive. Strong evidence was defined as consistent findings (> or =80%) in at least two high quality cohorts. We found strong evidence that the use of multiple drugs (3/3 cohorts, effect sizes 1.30-1 xs 0.30), antidepressants (10/12 cohorts, effect sizes 1.10-7.60), and anti-anxiety drugs (2/2 cohorts, effect sizes 1.22-1.32) is associated with increased fall risk. The evidence for the association of other psychoactive drug classes with fall risk was limited or inconclusive.

CONCLUSIONS

Research on the contribution of psychoactive drugs to fall risk in nursing home residents with dementia is limited. The scarce evidence shows, however, that multiple drugs, antidepressants and anti-anxiety drugs increase fall risk in nursing home populations with residents with dementia.

Depressive symptoms as a risk factor for unintentional injury: a cohort study in a rural county

OBJECTIVE

The authors used data from a population based prospective cohort study to determine if depressive symptoms predicted incidence of unintentional injury.

METHODS

The Keokuk County Rural Health Study, based in Iowa, is a prospective cohort study of health status that includes injury outcomes. Depressive symptoms were measured using the 11-item Center for Epidemiologic Studies Depression Scale at the beginning of the study on 1493 participants. Quarterly follow up phone calls were made to measure injury incidence.

RESULTS

471 injuries were reported for an overall injury rate of 9.8 per 100 person-years. Crude injury rates were significantly higher for those with depressive symptoms (p = 0.0003). Those with depressive symptoms had a 41% increased risk for injury after controlling for antidepressant medication use, gender, prior injury, income, and sleepiness (RR = 1.41, 95% CI 1.10 to 1.80). Depressive symptoms remained a risk factor for injury regardless of current antidepressant medication use (no medication use, RR = 1.43, 95% CI 1.09 to 1.88; medication use, RR = 1.31, 95% CI 0.76 to 2.26).

CONCLUSIONS

Depressive symptoms were found to be risk factors for unintentional injury. Medical practitioners should consider talking about safety with their patients, especially those reporting symptoms of depression, and recognize that an increased risk for injury remains until the depressive symptoms subside.

Use of selective serotonin reuptake inhibitors and sleep disturbances in community-dwelling older women

OBJECTIVES

To determine the association between use of selective serotonin reuptake inhibitors (SSRIs) and objective measures of sleep disturbances in older community-dwelling women, including women without evidence of depression.

DESIGN

Cross-sectional study.

SETTING

Four U.S. clinical centers.

PARTICIPANTS

Two thousand eight hundred fifty-three women aged 71 and older (2,630 nonusers of antidepressants and 223 taking SSRIs alone, not in combination with other antidepressants).

MEASUREMENTS

Medication use, assessed using an interviewer-administered questionnaire with verification of use from medication containers and computerized dictionary used to categorize type of medication; evidence of depression assessed using self-report or a score of 6 or higher on the Geriatric Depression Scale; and sleep parameters measured using a wrist actigraph, with data collected for an average of four consecutive 24-hour periods.

RESULTS

Of the overall cohort of 2,853 women and of 2,337 women without evidence of depression, sleep disturbances were more common in women taking SSRIs than in those not taking antidepressants. After excluding women with evidence of depression and adjusting for multiple potential confounders, women taking SSRIs were more likely to have a sleep duration of 5 hours or less (multivariate odds ratio (MOR)=2.15, 95% confidence interval (CI)=1.04-4.47), sleep efficiency less than 70% (MOR=2.37, 95% CI=1.32-4.25), sleep latency of 1 hour or more (MOR=3.99, 95% CI=2.29-6.96) and eight or more long wake episodes (MOR=1.75, 95% CI=0.99-3.10).

CONCLUSION

SSRI use by older women, including those without evidence of depression, is associated with a greater likelihood of sleep disturbances, including poorer sleep efficiency, longer sleep latency, and sleep fragmentation, manifested by multiple long wake episodes. These results add to the uncertainty regarding risks and benefits of SSRI use in aged populations.

Medication use as a risk factor for falls among hospitalized elderly patients

PURPOSE

The relationship between medication use and falls among hospitalized elderly patients was studied.

METHODS

Sixty-two patients 65 years of age or older who fell during hospitalization were randomly selected from incident reports of falls and matched for age, sex, and discharge date with 62 patients who did not fall. Data on demographic characteristics, vital signs, laboratory test variables, drug therapy, and the presence of other known risk factors for falls were collected retrospectively and compared between the groups.

RESULTS

Nonsteroidal antiinflammatory drug (NSAID) use was more frequent in patients who fell than in control patients. NSAID use was a significant predictor of falls and was associated with a 10-fold increase in the likelihood of falling. Opioid analgesics were given more frequently to control patients and were not associated with falls. Dementia, the only non-medication-related independent predicator of falls, was associated with a 21-fold greater risk of falling.

CONCLUSION

In hospitalized elderly patients, there was a significant association between NSAID use and falls, an effect largely accounted for by low-dose aspirin.

Bright light treatment of depression for older adults [ISRCTN55452501]

BACKGROUND

The incidence of insomnia and depression in the elder population is significant. It is hoped that use of light treatment for this group could provide safe, economic, and effective rapid recovery.

METHODS

In this home-based trial we treated depressed elderly subjects with bright white (8,500 Lux) and dim red (<10 Lux) light for one hour a day at three different times (morning, mid-wake and evening). A placebo response washout was used for the first week. Wake treatment was conducted prior to the initiation of treatment, to explore antidepressant response and the interaction with light treatment. Urine and saliva samples were collected during a 24-hour period both before and after treatment and assayed for aMT6s and melatonin respectively to observe any change in circadian timing. Subjects wore a wrist monitor to record light exposure and wrist activity. Daily log sheets and weekly mood (GDS) and physical symptom (SAFTEE) scales were administered. Each subject was given a SCID interview and each completed a mood questionnaire (SIGH-SAD-SR) before and after treatment. Also, Hamilton Depression Rating (SIGH-SAD version) interviews were conducted by a researcher who was blind to the treatment condition. A control group of healthy, age-matched, volunteers was studied for one day to obtain baseline data for comparison of actigraphy and hormone levels.

RESULTS

Eighty-one volunteers, between 60 and 79 years old, completed the study. Both treatment and placebo groups experienced mood improvement. Average GDS scores improved 5 points, the Hamilton Depression Rating Scale (HDRS) 17 scores (extracted from the self-rated SIGH-SAD-SR) improved 6 points. There were no significant treatment effects or time-by-treatment interactions. No significant adverse reactions were observed in either treatment group. The assays of urine and saliva showed no significant differences between the treatment and placebo groups. The healthy control group was active earlier and slept earlier but received less light than the depressed group at baseline.

CONCLUSION

Antidepressant response to bright light treatment in this age group was not statistically superior to placebo. Both treatment and placebo groups experienced a clinically significant overall improvement of 16%.

Long-term mental distress, bone mineral density and non-vertebral fractures. The Tromsø Study

The purpose of this study was to examine, prospectively, the risk of non-vertebral fractures and low bone mineral density in a population-based cohort with respect to indicators of subjective mental distress. In 1979-1980 all males born 1925-1959 and all females born 1930-1959 living in Tromsø were invited (21,441; response rate, 78%). The same individuals were invited to the subsequent studies in 1986-1987 and 1994-1995 (74% attended the first two, and 71% attended all three surveys). Non-vertebral fractures were registered by linkage to the hospital X-ray register for the period 1988-1995, and forearm bone mineral density (BMD) was available in a subsample of 4,690 who had attended three times. Questions about mental distress (depression, insomnia and coping problems) were repeated three times and analyzed as cumulated exposure. Women who reported being depressed at two time points had an adjusted odds ratio (OR) =2.5 (95% confidence interval [CI] 1.3-4.9) for sustaining a non-vertebral fracture and OR=3.1 (95% CI 1.3-7.2) for sustaining an osteoporotic fracture, compared with those without depression on any occasion. The corresponding odds ratios for those with coping problems at two time points were slightly higher, whereas sleeping problems seem only to be weakly associated with non-vertebral fractures. The pattern of associations and the magnitude of OR estimates were mainly the same in women younger than 50 years and those 50 years and older. Women using nerve medicine and reporting depression twice had an odds ratio of 4.4 (95% CI 1.1-17.7) for sustaining a non-vertebral fracture, and those using nerve medicine and reporting coping problems twice had a corresponding OR 4.7 (95% CI 1.2-18.4). Among men no significant associations were found for either fracture type. No association was found between mean BMD and number of times reporting depression, insomnia or coping problems, in women or men. Long-term mental distress is associated with risk of all non-vertebral fractures and osteoporotic fractures in middle-aged women, but not in men. Mental distress itself seems to be more important than the use of nerve medicine.

An analysis of administrative data found that proximate clinical event ratios provided a systematic approach to identifying possible iatrogenic risk factors or complications

OBJECTIVE

A method to generate hypotheses about iatrogenic risk factors and complications from administrative data was developed and tested using hospitalization of the elderly for depression as a model.

STUDY DESIGN AND SETTING

Hospital claims were selected for 30,998 elderly inpatients admitted for the first time for depression. Common principal diagnoses and procedures in hospitalizations within 90 days of the index depression admission were tallied. For each of these proximate clinical events, the ratio of how many happened before the index admission to how many occurred afterward was calculated. Ratios diverging markedly from unity were identified to generate hypotheses about possible risk factors associated with depression and complications associated with its management.

RESULTS

Hospitalization for degenerative joint disease or back problems; abdominal pain or gastritis and duodenitis; coronary artery disease; or cerebrovascular disease was more common before an index depression admission than after it, as were coronary artery surgery, total knee replacement, and cholecystectomy. Admissions for fracture of the femoral neck--an established iatrogenic complication--were disproportionately likely after the index admission. So were admissions for aspiration pneumonia or acute respiratory failure.

CONCLUSION

Proximate clinical event ratios provide a systematic approach to screening administrative data to identify candidates for further evaluation as possible iatrogenic risk factors or complications.

PREVENTING FALLS in Acute Care: An Innovative Approach

Falls among elderly individuals have been significant sources of disability and death. Falls have affected as many as 10% of older adults during an acute care inpatient stay. The acute care environment has contributed to elderly patient falls. Additionally, manifestations of acute illness, polypharmacy, and medication side effects have been risk factors for falls in the acute care setting. Individualized fall prevention strategies, initial patient assessments, and ongoing patient reassessments have been linked to a decrease in falls in the acute care setting. Approaches to fall prevention have included identification of high-risk patients, communication among staff and family members about an individual's risk of falls, and both case-specific and universal interventions for fall prevention. The purpose of this article is to describe a fall prevention program instituted in an acute care setting in southern Arizona that has produced encouraging results. Moreover, this article addresses individualizing interventions through a continuous clinical feedback loop, which provides patient care areas with relevant information about their patients who fell and recommendations for improving fall prevention.

Correlates of falling during 24 h among elderly Danish community residents

OBJECTIVES

To identify dietary, medical, and environmental correlates of falling during the last 24 h among elderly community residents. The limited accuracy of recall of falls in the elderly in previous studies was the reason for a 24-h time frame.

METHODS

The study composes 4281 community residents aged 66+ years. The statistical analyses included Pearson's chi(2) test and multiple logistic regression.

RESULTS

Mutually independent correlates of falls were a family history of fracture (OR, 3.0; 95% CI: 1.3-7.1); osteoarthrosis of the knee (OR, 2.9; 95% CI: 1.3-6.2); dizziness (OR, 4.1; 95% CI: 1.9-8.9); a diet not including sour dairy products (OR, 3.0; 95% CI: 1.4-6.3) or fish (OR, 3.4; 95% CI: 1.5-7.5); drinking tea (OR, 5.8; 95% CI 2.15-15.30); needing help for shopping (OR, 3.9; 95% CI: 1.6-9.3); and for administration of medicine (OR, 9.0; 95% CI: 2.0-40.6). Independent environmental correlates were vinyl on the floor in the bathroom (OR, 6.6; 95% CI: 2.1-20.9) and using indoor footwear without soles (OR, 5.5; 95% CI: 2.3-13.4).

CONCLUSION

The present analyses suggest that several factors are associated to the risk of falling among elderly community residents. It appears relevant for further studies to test if modifications of the potential risk factors identified may reduce falls among community dwelling older persons.

Risk factors for hip fracture in skilled nursing facilities: who should be evaluated?

This paper aims to identify risk factors for hip fracture in Medicare skilled nursing facility (SNF) residents and to develop a predictive model based on routinely collected administrative data (the Minimum Data Set, MDS) to identify high-risk residents. Prospective cohort study of 28,807 North Carolina Medicare SNF residents aged >65 years with a complete MDS assessment in 1999. Demographic, historical, physical, cognitive, behavioral, activities of daily living, and medication variables were obtained from the MDS. Hip fracture occurring after the first MDS assessment identified by ICD-9 code was the outcome measure. Variables significantly associated with hip fracture by chi-square test in a randomly selected derivation sample were combined in a multivariable logistic model and in models stratified by gender. The models were validated in the remaining subjects. Variables significantly related to subsequent hip fracture in the full cohort include: female sex (odds ratio 1.3, 95% confidence interval 1.0-1.7), white race (2.3, 1.6-3.5), age (1.03 per year, 1.01-1.04), cognitive impairment (1.4, 1.8-1.8), incontinence (0.68, 0.5-0.9), prior fractures (1.6, 1.2-2.1), and prior falls (1.4, 1.2-1.8). In ambulatory non-Hispanic white women, anxiety (1.5, 1.0-2.1), anxiolytic use (1.4, 1.1-1.9), wandering (1.4, 1.0-2.2), and training in community skills (1.4, 1.1-1.8) were new significant variables. For ambulatory non-Hispanic white men, education level (2.0, 1.2-3.2), weight loss (0.5, 0.2-1.0), history of osteoporosis (3.0, 1.3-6.7), pathologic bone fracture (9.7, 2.2-42.6), COPD (2.1, 1.3-3.5), glaucoma (2.6, 1.0-6.2), and standing balance impairment (1.8, 1.0-3.3) were also significant. All models were highly correlated with subsequent hip fracture, but the discriminative ability was limited (c statistic 0.678). Risk factors explained more of hip fracture risk in non-Hispanic white men (c statistic 0.793) than non-Hispanic white women (0.658). Risk factors for hip fracture in Medicare SNF residents have similarities and differences from those previously identified in community-dwelling older adults. Osteoporosis screening and intervention should focus on the healthiest, most independent subset of residents who have the greatest fracture risk.

Misclassification of current benzodiazepine exposure by use of a single baseline measurement and its effects upon studies of injuries

PURPOSE

Measurement of drug exposure is a major methodologic challenge for pharmacoepidemiologic studies of acute effects of medications taken intermittently. If the effect is plausible only during periods of active drug use, daily (or even more frequent) exposure measurement is optimal. Benzodiazepines, episodically used hypnotics and anxiolytics, impair psychomotor function and some epidemiologic studies have reported users have increased risk of unintentional injuries. However, several prospective cohort studies of this question defined benzodiazepine exposure status from a single baseline measurement, and these have not consistently reported increased risk. We used data from an historical cohort study to demonstrate the extent of misclassification potentially induced by this practice.

METHODS

The cohort consisted of 2510 Tennessee nursing home residents 65 years of age or older identified in a prior study of antidepressants and falls. Both baseline users (any in 7 days preceding start of follow-up) and current use (use on a given day of follow-up) of benzodiazepines were determined from facility medication administration records, which record information on drugs given to the resident each day. Falls were ascertained from nursing home incident reports and medical records. The effect of benzodiazepine exposure for each ascertainment method was estimated from incidence rate ratios adjusted for multiple fall risk factors by Poisson regression.

RESULTS

The 666 baseline benzodiazepine users had current use on 44.6% (95% CI, 40.2-49.2%) of follow-up person-days; baseline non-users had current use for 3.7% of days (2.8-4.7%). Misclassification increased with length of follow-up and with quintile of fall risk. The adjusted fall incidence rate ratios for the baseline user and current use definitions were 1.02 (95% CI, 0.95-1.10) and 1.44 (1.33-1.56), respectively.

CONCLUSION

These findings strongly suggest that to avoid potentially serious misclassification, studies of the acute effects of benzodiazepines and other drugs taken intermittently need to track exposure on a day-by-day basis.

Central nervous system-active medications and risk for falls in older women

OBJECTIVES

To determine whether current use of central nervous system (CNS)-active medications, including benzodiazepines, antidepressants, anticonvulsants, and narcotics, increases the risk for subsequent falls.

DESIGN

Prospective cohort study.

SETTING

Four clinical centers in Baltimore, Maryland; Portland, Oregon; Minneapolis, Minnesota; and the Monongahela Valley, Pennsylvania.

PARTICIPANTS

Eight thousand one hundred twenty-seven women aged 65 and older participating in the fourth examination of the Study of Osteoporotic Fractures between 1992 and 1994.

MEASUREMENTS

Current use of CNS-active medications was assessed with an interviewer-administered questionnaire with verification of use from medication containers. A computerized dictionary was used to categorize type of medication from product brand and generic names. Incident falls were reported every 4 months for 1 year after the fourth examination.

RESULTS

During an average follow-up of 12 months, 2,241 women (28%) reported falling at least once, including 917 women (11%) who experienced two or more (frequent) falls. Compared with nonusers, women using benzodiazepines (multivariate odds ratio (MOR) = 1.51, 95% confidence interval (CI) = 1.14-2.01), those taking antidepressants (MOR = 1.54, 95% CI = 1.14-2.07), and those using anticonvulsants (MOR = 2.56, 95% CI = 1.49-4.41) were at increased risk of experiencing frequent falls during the subsequent year. We found no evidence of an independent association between narcotic use and falls (MOR = 0.99 for frequent falling, 95% CI = 0.68-1.43). Among benzodiazepine users, both women using short-acting benzodiazepines (MOR = 1.42, 95% CI = 0.98-2.04) and those using long-acting benzodiazepines (MOR = 1.56, 95% CI = 1.00-2.43) appeared to be at greater risk of frequent falls than nonusers, although the CIs overlapped 1.0. We found no evidence to suggest that women using selective serotonin-reuptake inhibitors (MOR = 3.45, 95% CI = 1.89-6.30) had a lower risk of frequent falls than those using tricyclic antidepressants (MOR 1.28, 95% CI = 0.90-1.84).

CONCLUSIONS

Community-dwelling older women taking CNS-active medications, including those taking benzodiazepines, antidepressants, and anticonvulsants, are at increased risk of frequent falls. Minimizing use of these CNS-active medications may decrease risk of future falls. Our results suggest that fall risk in women taking benzodiazepines is at best marginally decreased by use of short-acting preparations. Similarly, our findings indicate that preferential use of selective serotonin-reuptake inhibitors is unlikely to reduce fall risk in older women taking antidepressants.

Risk factors for falling in a psychogeriatric unit

OBJECTIVE

To identify risk factors associated with falls in a psychogeriatric inpatient population.

DESIGN

Retrospective cohort study.

SETTING

A psychogeriatric inpatient unit in a Brown University affiliated psychiatric hospital.

PARTICIPANTS

A total of 1834 men and women who represented all admissions to the psychogeriatric inpatient unit between January 1992 and December 1995.

RESULTS

Over the study period a total of 175 falls were recorded, giving a fall rate of 9.5%. Using a logistic regression model, six variables were found to be independently associated with an increased risk of falling: female gender, electroconvulsive therapy (ECT), mood stabilizers, cardiac arrhythmias, Parkinson's syndrome and dementias. Falls and ECT were associated with longer hospital stay, when adjusted for confounders including ECT.

CONCLUSIONS

These findings support previous results and identify ECT as a possible risk factor for falling in a hospital setting.

The effects of antidepressants on obstructed and unobstructed gait in healthy elderly people

BACKGROUND

Elderly patients treated with antidepressants for depression are at high risk for injury due to falling. The primary purpose of this study was to determine the effects of amitriptyline, desipramine, and paroxetine on the gait of healthy elderly subjects during unobstructed and obstructed (i.e., stepping over obstacles) gait. Psychomotor and mood tests were also performed.

METHODS

A randomized, crossover, four-period, double-blind, placebo-controlled laboratory trial was performed. Twelve healthy elderly subjects (average age, 67 years; range, 65-72 years) were tested. Subjects were assigned the three antidepressant drugs or a placebo in a random order. Single doses of amitriptyline 50 mg, desipramine 50 mg, paroxetine 20 mg, or placebo were given 4 hours prior to gait testing. Temporal-distance measures and kinematics of the lower trailing limb (i.e., limb going over obstacle last) were obtained.

RESULTS

Compared with placebo, amitriptyline significantly reduced gait velocity by as much as 8.0% (p = .028), cadence by as much as 4.9% (p = .012), angular velocity of hip flexion by as much as 10.0% (p = .004), and angular velocity of knee flexion by as much as 8.3% (p = 018) during the crossing strides when stepping over obstacles. Except for knee flexion angle, unobstructed gait was not affected. Amitriptyline affected integrative capacity of the central nervous system (CNS) and ability to concentrate as measured by psychomotor and mood tests.

CONCLUSIONS

The results for amitriptyline suggest that the subjects slowed their obstacle crossing speeds as a result of reduced CNS integrative capacities. Neither paroxetine nor desipramine significantly affected gait, psychomotor function, or mood.

Electroconvulsive therapy and falls in the elderly

Electroconvulsive therapy (ECT) is commonly used in the practice of geriatric psychiatry. Although it has been found to be both safe and effective, one of the most common complications associated with ECT is falls. A logistic regression model was created to identify independent risk factors for falls in the elderly. Two risk factors were identified: the number of ECT treatments and the diagnosis of Parkinson disease. Further studies are needed to develop strategies aimed at reducing the number of falls. In the meantime, clinicians need to be aware that falls represent an important complication associated with ECT.

Benzodiazepines and the risk of falls in nursing home residents

CONTEXT

For nursing home residents who require a benzodiazepine, short-acting agents are recommended, primarily to avoid increased risk of falls and other injuries associated with the long-acting agents. However, much of the data for the clinical outcomes of falls and injuries comes from community-dwelling older people.

OBJECTIVE

To quantify the rate of falls among nursing home residents taking benzodiazepines and how this varies with drug elimination half-life.

DESIGN

Historical cohort study.

POPULATION

A total of 2510 residents of 53 Tennessee nursing homes, classified according to benzodiazepine use on each day of follow-up.

OUTCOME MEASURES

Falls occurring during study follow-up.

RESULTS

After adjustment for differences in resident characteristics, benzodiazepine users had a 44% increased rate of falls (adjusted rate ratio 1.44 [95% confidence interval, 1.33-1.56]). The adjusted rate ratio increased from 1.30 (1.12-1.52) for a dose equivalent to < or = 2 mg of diazepam, to 2.21 (1.89-2.60, P < .001) for a dose of > 8 mg. The rate of falls was greatest in the 7 days after the benzodiazepine was started (rate ratio of 2.96 [2.33-3.75]) but remained elevated (1.30 [1.17-1.44]) after the first 30 days of therapy. Drugs with elimination half-lives of <12, 12-23, and > or = 24 hours had adjusted rate ratios of 1.15 (0.94-1.40), 1.45 (1.33-1.59), and 1.73 (1.40-2.14), respectively. Users of hypnotics with elimination half-lives <12 hours had an increased rate of falls occurring during the night (adjusted rate ratio 2.82 [2.02-3.94]).

CONCLUSIONS

Although the risk of falls among nursing home residents receiving short-acting benzodiazepines is less than that for the long-acting agents, these drugs are associated with a materially increased risk of nocturnal falls.

Psychiatric unit fall events

Patient falls in psychiatric units may have an impact on patient outcomes. Fall risk assessment among psychiatric patients is an important issue. Gait/balance problems and history of falling are important considerations in assessing psychiatric patients for fall risk.

Drugs and falls in older people: a systematic review and meta-analysis: II. Cardiac and analgesic drugs

OBJECTIVES

To evaluate critically the evidence linking specific classes of cardiac and analgesic drugs to falls in older people.

DESIGN

Fixed-effects meta-analysis.

DATA SOURCES

English-language articles in MEDLINE (1966 - March 1996) indexed under accidents or accidental falls and aged or age factors; bibliographies of retrieved papers.

STUDY SELECTION

Systematic evaluation of cardiac or analgesic drug use and any fall in people aged 60 years and older.

DATA EXTRACTION

Study design, inclusion and exclusion criteria, setting, sample size, response rate, mean age, method of medication verification and fall assessment, fall definition, and the number of fallers and nonfallers taking specific classes of cardiac and analgesic drugs.

RESULTS

Twenty nine studies met inclusion criteria. None were randomized controlled trials. For one or more falls, the pooled Odds Ratio (95% Confidence Interval) was 1.08 (1.02-1.16) for diuretic use, 1.06 (0.97-1.16) for thiazide diuretics, 0.90 (0.73-1.12) for loop diuretics, 0.93 (0.77-1.11) for beta-blockers, 1.16 (0.87-1.55) for centrally acting antihypertensives, 1.20 (0.92-1.58) for ACE inhibitors, 0.94 (0.77-1.14) for calcium channel blockers, 1.13 (0.95-1.36) for nitrates, 1.59 (1.02-2.48) for type Ia antiarrhythmics, and 1.22 (1.05-1.42) for digoxin use. For analgesic drugs, the pooled OR was 0.97 (0.78-1.20) for narcotic use, 1.09 (0.88-1.34) for nonnarcotic analgesic use, 1.16 (0.97-1.38) for NSAID use, and 1.12 (0.80-1.57) for aspirin use. There was no statistically significant heterogeneity of pooled odds ratios. There were no differences between the pooled odds ratios for studies with mean subject age <75 versus > or =75 years old or for studies in communities with <35% versus > or =35% fallers. In studies of the relationship between psychotropic, cardiac, or analgesic drugs and falls, subjects reporting the use of more than three or four medications of any type were at increased risk of recurrent falls.

CONCLUSION

Digoxin, type IA antiarrhythmic, and diuretic use are associated weakly with falls in older adults. No association was found for the other classes of cardiac or analgesic drugs examined. The evidence to date, however, is based solely on observational data, with minimal adjustment for confounders, dosage, or duration of therapy. Older adults taking more than three or four medications were at increased risk of recurrent falls. As a result of the incidence of falls and their consequences in this population, programs designed to decrease medication use should be evaluated for their impact on fall rates.

Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs

OBJECTIVES

To evaluate critically the evidence linking psychotropic drugs with falls in older people.

DESIGN

Fixed-effects meta-analysis.

DATA SOURCES

English-language articles in MEDLINE (1966 - March 1996) indexed under accidents or accidental falls and aged or age factors; bibliographies of retrieved papers.

STUDY SELECTION

Systematic evaluation of sedative/hypnotic, antidepressant, or neuroleptic use with falling in people aged 60 and older.

DATA EXTRACTION

Study design, inclusion and exclusion criteria, setting, sample size, response rate, mean age, method of medication verification and fall assessment, fall definition, and the number of fallers and non-fallers taking specific classes of psychotropic drugs.

RESULTS

Forty studies, none randomized controlled trials, met eligibility criteria. For one or more falls, the pooled odds ratio (95% confidence interval) was 1.73 (95%CI, 1.52-1.97) for any psychotropic use; 1.50 (95%CI, 1.25-1.79) for neuroleptic use; 1.54 (95%CI, 1.40-1.70) for sedative/hypnotic use; 1.66 (95%CI, 1.4-1.95) for any antidepressant use (mainly TCAs); 1.51 (95%CI, 1.14-2.00) for only TCA use; and 1.48 (95%CI, 1.23-1.77) for benzodiazepine use, with no difference between short and long acting benzodiazepines. For neuroleptics in psychiatric inpatients, the pooled OR was 0.41 (95%CI, 0.21-.82); for all other patients, the pooled OR was 1.66 (95%CI, 1.38-2.00). Comparing > or =1 with > or = 2 falls, mean subject age <75 versus > or =75 years old, communities with <35% versus > or =35% fallers, or subject place of residence did not affect the pooled OR. Increased falls occurred in patients taking more than one psychotropic drug.

CONCLUSION

There is a small, but consistent, association between the use of most classes of psychotropic drugs and falls. The evidence to date, however, is based solely on observational data, with minimal adjustment for confounders, dosage, or duration of therapy. The incidence of falls and their consequences in this population necessitate that future large randomized controlled trials of any medication in older persons should measure falls prospectively as an adverse outcome event.

Antidepressants and the risk of falls among nursing home residents

BACKGROUND

In nursing home residents, the use of tricyclic and other heterocyclic antidepressants is associated with an increased risk of falls. The newer selective serotonin-reuptake-inhibitor antidepressants are largely free of the side effects of the tricyclic agents thought to cause falls and so have been hypothesized to be safer for those at high risk for falls.

METHODS

We retrospectively identified an inception cohort of 2428 nursing home residents in Tennessee who were new users of tricyclic antidepressants (665 subjects), selective serotonin-reuptake inhibitors (612 subjects), or trazodone (304 subjects) or nonusers of antidepressants (847 subjects). We ascertained the number of falls during therapy and during a similar follow-up period for nonusers, then calculated the rate ratios for falls with adjustments for an extensive set of potential confounding factors.

RESULTS

The new users of each type of antidepressant had higher rates of falls than the nonusers, with adjusted rate ratios of 2.0 (95 percent confidence interval, 1.8 to 2.2) for tricyclic antidepressants, 1.8 (1.6 to 2.0) for selective serotonin-reuptake inhibitors, and 1.2 (1.0 to 1.4) for trazodone. The rate ratios increased with the daily dose for tricyclic antidepressants, reaching 2.4 (95 percent confidence interval, 2.1 to 2.8) for doses of 50 mg or more of amitriptyline or its equivalent, and for the serotonin-reuptake inhibitors, reaching 1.9 (1.7 to 2.2) for 20 mg or more of fluoxetine or its equivalent. The elevated rates of falls persisted through the first 180 days of therapy and beyond.

CONCLUSIONS

In this large study of nursing home residents, there was little difference in rates of falls between those treated with tricyclic antidepressants and those treated with selective serotonin-reuptake inhibitors. Hence, the preferential use of the newer antidepressants is unlikely to reduce the higher rate of falls among nursing home residents taking antidepressants.