Abstract
Background and objective
The use of psychotropic medication and cardiovascular medication has been associated
with an increased risk of falling. However, other frequently prescribed medication
classes are still under debate as potential risk factors for falls in the older population.
The aim of this systematic review and meta-analysis is to evaluate the associations
between fall risk and nonpsychotropic and noncardiovascular medications.
Methods and design
A systematic review and meta-analysis. A search was conducted in Medline, PsycINFO,
and Embase. Key search concepts were “falls,” “aged,” “medication,” and “causality.”
Studies were included that investigated nonpsychotropic and noncardiovascular medications
as risk factors for falls in participants ≥60 years or participants with a mean age
≥70 years. A meta-analysis was performed using the generic inverse variance method,
pooling unadjusted and adjusted odds ratio (OR) estimates separately.
Results
In a qualitative synthesis, 281 studies were included. The results of meta-analysis
using adjusted data were as follows (a pooled OR [95% confidence interval]): analgesics,
1.42 (0.91-2.23); nonsteroidal anti-inflammatory drugs (NSAIDs), 1.09 (0.96-1.23);
opioids, 1.60 (1.35-1.91); anti-Parkinson drugs, 1.54 (0.99-2.39); antiepileptics,
1.55 (1.25-1.92); and polypharmacy, 1.75 (1.27-2.41). Most of the meta-analyses resulted
in substantial heterogeneity that did not disappear after stratification for population
and setting in most cases. In a descriptive synthesis, consistent associations with
falls were observed for long-term proton pump inhibitor use and opioid initiation.
Laxatives showed inconsistent associations with falls (7/20 studies showing a positive
association).
Conclusion
Opioid and antiepileptic use and polypharmacy were significantly associated with increased
risk of falling in the meta-analyses. Long-term use of proton pump inhibitors and
opioid initiation might increase the fall risk. Future research is necessary because
the causal role of some medication classes as fall-risk-increasing drugs remains unclear,
and the existing literature contains significant limitations.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of the American Medical Directors AssociationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Home and recreational safety. Important facts about falls.(Available at:)http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.htmlDate accessed: May 1, 2017
EuroSafe. Injuries in the European Union, summary on injury statistics 2012-2014. Amsterdam; 2016.
- The direct costs of fatal and non-fatal falls among older adults—United States.J Saf Res. 2016; 58: 99-103
- Trends in fall-related hospital admissions in older persons in the Netherlands.Arch Intern Med. 2010; 170: 905-911
- Trends in fall-related injuries among older adults treated in emergency departments in the USA.Inj Prev. 2014; 20: 421-423
- Hospitalized fall-related injury trends in Sweden between 2001 and 2010.Int J Inj Contr Saf Promot. 2016; 23: 277-283
- Drugs and falls in older people: A systematic review and meta-analysis: I. Psychotropic drugs.J Am Geriatr Soc. 1999; 47: 30-39
- Drugs and falls in older people: A systematic review and meta-analysis: II. Cardiac and analgesic drugs.J Am Geriatr Soc. 1999; 47: 40-50
- Meta-analysis of the impact of 9 medication classes on falls in elderly persons.Arch Intern Med. 2009; 169: 1952-1960
- Medication as a risk factor for falls: Critical systematic review.J Gerontol A Biol Sci Med Sci. 2007; 62: 1172-1181
- Systematic review: Use of sedatives and hypnotics, antidepressants and benzodiazepines in older people significantly increases their risk of falls.Evid Based Med. 2010; 15: 59
- Medications associated with falls in older people: Systematic review of publications from a recent 5-year period.Eur J Clin Pharmacol. 2015; 71: 1429-1440
- Psychotropic drugs and falls in the elderly people: Updated literature review and meta-analysis.J Aging Health. 2011; 23: 329-346
- Estimation of the risk factors for falls in the elderly: Can meta-analysis provide a valid answer?.Geriatr Gerontol Int. 2013; 13: 250-263
- Interventions for preventing falls in older people living in the community.Cochrane Database Syst Rev. 2012; : CD007146
- [Cost] effectiveness of withdrawal of fall-risk increasing drugs versus conservative treatment in older fallers: Design of a multicenter randomized controlled trial (IMPROveFALL-study).BMC Geriatr. 2011; 11: 48
- Effects of medication reviews performed by a physician on treatment with fracture-preventing and fall-risk-increasing drugs in older adults with hip fracture—A randomized controlled study.J Am Geriatr Soc. 2013; 61: 1464-1472
- Software survey: VOSviewer, a computer program for bibliometric mapping.Scientometrics. 2010; 84: 523-538
- Development of a common outcome data set for fall injury prevention trials: The Prevention of Falls Network Europe consensus.J Am Geriatr Soc. 2005; 53: 1618-1622
- The prevention of falls in later life. A report of the Kellogg International Work Group on the Prevention of Falls by the Elderly.Dan Med Bull. 1987; 34: 1-24
- Risk factors for falls among elderly persons living in the community.N Engl J Med. 1988; 319: 1701-1707
- ATC.(Available at:)http://www.whocc.no/atc/structure_and_principles/Date accessed: September 1, 2016
- The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses.(Available at:)http://www.ohri.ca/programs/clinical_epidemiology/oxford.aspDate accessed: September 1, 2016
- The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials.BMJ. 2011; 343: d5928
- Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0.(The Cochrane Collaboration, 2011. Available at:) (Updated March 2011)
- Different risk-increasing drugs in recurrent versus single fallers: Are recurrent fallers a distinct population?.Drugs Aging. 2013; 30: 845-851
- Drugs and falls in community-dwelling older people: A national veterans study.Clin Ther. 2006; 28: 619-630
- Predictors for recurrent falls among the home-dwelling elderly.Scand J Prim Health Care. 1995; 13: 294-299
- Falls among elderly nursing home residents.Public Health. 1993; 107: 89-96
- Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: Case–control and cohort studies.BMJ. 1997; 315: 1049-1053
- Falls in 84- to 85-year-old people living at home.Accid Anal Prev. 1992; 24: 527-537
- Central nervous system-active medications and risk for falls in older women.J Am Geriatr Soc. 2002; 50: 1629-1637
- Central nervous system medications and falls risk in men aged 60-75 years: The Study on Male Osteoporosis and Aging (SOMA).Age Ageing. 2013; 42: 121-124
- Association between central nervous system drugs and recurrent falling based on prospective falls registration in nursing homes.Eur Geriatr Med. 2012; 3: 82-86
- Predictors for falls and fractures in the Longitudinal Aging Study Amsterdam.J Bone Miner Res. 1998; 13: 1932-1939
- Medication use and falls in community-dwelling older persons.Age Ageing. 2003; 32: 503-509
- Predicting falls among patients in a rehabilitation hospital.Am J Phys Med Rehabil. 1989; 68: 139-146
- Factors associated with falls during hospitalization in an older adult population.Res Theory Nurs Pract. 2011; 25: 127-148
- Risk factors for serious falls among community-based seniors: Results from the National Population Health Survey.Can J Aging. 2002; 21: 103-116
- Causes and correlates of recurrent falls in ambulatory frail elderly.J Gerontol. 1991; 46: M114-M122
- Fall Risk Assessment in Geriatric-Psychiatric Inpatients to Lower Events (FRAGILE).J Gerontol Nurs. 2011; 37 (quiz 32–33): 22-30
- Medications and chronic diseases as risk factors for falling injuries in the elderly.Scand J Soc Med. 1993; 21: 264-271
- Medications and multiple falls in elderly people: The St Louis OASIS study.Age Ageing. 1991; 20: 455-461
- Falls in rural elders: An empirical study of risk factors.J Am Board Fam Pract. 2002; 15: 178-182
- Falls of elderly rural home health clients.Home Health Care Serv Q. 1998; 17: 41-51
- Medical conditions and medications as risk factors of falls in the inpatient older people: A case-control study.Int J Geriatr Psychiatry. 2011; 26: 602-607
- Medication use and fall-risk assessment for falls in an acute care hospital.Geriatr Gerontol Int. 2015; 15: 856-863
- The risk of fall injury in relation to commonly prescribed medications among older people—A Swedish case-control study.Eur J Public Health. 2015; 25: 527-532
- Psychotropic drugs and falling accidents among the elderly: A nested case control study in the whole population of Scania, Sweden.J Epidemiol Community Health. 2010; 64: 440-446
- Medication use as a risk factor for falls among hospitalized elderly patients.Am J Health Syst Pharm. 2005; 62: 2495-2499
- Prevalence and risk factors for falls among the elderly in primary healthcare centers (PHC) in Qatar.Med J. 2011; 2011: 7
- Drugs and falls in older people in geriatric care settings.Aging Clin Exp Res. 2004; 16: 270-276
- Changes in gait performance over several years are associated with recurrent falls status in community-dwelling older women at high risk of fracture.Age Ageing. 2015; 44: 287-293
- A simple clinical scale to stratify risk of recurrent falls in community-dwelling adults aged 65 years and older.Phys Ther. 2010; 90: 550-560
- Assessment of impact of medication use and dementia on fall risk in clients receiving home health care.Home Health Care Manage Pract. 2012; 24: 228-233
- Preclinical disability as a risk factor for falls in community-dwelling older adults.J Gerontol A Biol Sci Med Sci. 2008; 63: 314-320
- The physical performance test as a predictor of frequent fallers: A prospective community-based cohort study.Clin Rehabil. 2006; 20: 83-90
- Associations between falls and general health, nutrition, dental health and medication use in Swedish home-dwelling people aged 75 years and over.Health Soc Care Community. 2015; 23: 594-604
- Falls among the community-living elderly people in Hong Kong: A retrospective study.Hong Kong J Occup Ther. 2011; 21: 33-40
- Short Berg Balance Scale, BBS-9, as a predictor of fall risk among the aged: A prospective 12-month follow-up study.Aging Clin Exp Res. 2013; 25: 645-650
- Characteristics of polymedicated (≥4) elderly: A survey in a community-dwelling population aged 60 years and over.J Nutr Health Aging. 2014; 18: 87-91
- An epidemiological study of falls in older community-dwelling women: The Randwick falls and fractures study.Aust J Public Health. 1993; 17: 240-245
- Obesity and falls in older people: Mediating effects of disease, sedentary behavior, mood, pain and medication use.Arch Gerontol Geriatr. 2015; 60: 52-58
- The association between nursing diagnoses and the occurrence of falls observed among elderly individuals assisted in an outpatient facility.Rev Lat Am Enfermagem. 2007; 15: 311-317
- Balance impairment as a risk factor for falls in community-dwelling older adults who are high functioning: A prospective study.Phys Ther. 2010; 90: 338-347
- The development and validation of a brief performance-based fall risk assessment tool for use in primary care.J Gerontol A Biol Sci Med Sci. 2010; 65: 896-903
- Fall-risk screening test: A prospective study on predictors for falls in community-dwelling elderly.J Clin Epidemiol. 2001; 54: 837-844
- Depression as a predictor of falls amongst institutionalized elders.Aging Ment Health. 2012; 16: 763-770
- Risk factors for single and recurrent falls: A prospective study of falls in community dwelling seniors without cognitive impairment.Prev Med. 2013; 57: 511-517
- Assessing the quality of a non-randomized pragmatic trial for primary prevention of falls among older adults.Prev Sci. 2015; 16: 31-40
- Insomnia and hypnotic use, recorded in the minimum data set, as predictors of falls and hip fractures in Michigan nursing homes.J Am Geriatr Soc. 2005; 53: 955-962
- Association of depressive symptoms with recurrent falls: A cross-sectional elderly population based study and a systematic review.J Nutr Health Aging. 2013; 17: 152-157
- Differential risk factor profiles for indoor and outdoor falls in older people living at home in Nottingham.UK. Eur J Epidemiol. 1999; 15: 65-73
- Recurrent falls and dual task-related decrease in walking speed: Is there a relationship?.J Am Geriatr Soc. 2008; 56: 1265-1269
- Prevalence and impact of fall-risk-increasing drugs, polypharmacy, and drug-drug interactions in robust versus frail hospitalised falls patients: A prospective cohort study.Drugs Aging. 2014; 31: 225-232
- A screening tool with five risk factors was developed for fall-risk prediction in community-dwelling elderly.J Clin Epidemiol. 2011; 64: 1152-1160
- Risk factors for falls in a community-based prospective study of people 70 years and older.J Gerontol. 1989; 44: M112-M117
- Risk factors for falls among seniors: Implications of gender.Am J Epidemiol. 2015; 181: 521-531
- Predictors of falls and hospitalization outcomes in elderly patients admitted to an acute geriatric unit.Arch Gerontol Geriatr. 2009; 49: 142-145
- Is a fall just a fall: Correlates of falling in healthy older persons. The Health, Aging and Body Composition Study.J Am Geriatr Soc. 2003; 51: 841-846
- Development and validation of fall risk screening tools for use in residential aged care facilities.Med J Aust. 2008; 189: 193-196
- Falls in nonagenarians after 1-year of follow-up: The NonaSantfeliu study.Arch Gerontol Geriatr. 2008; 46: 15-23
- Polypharmacy cutoff and outcomes: Five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes.J Clin Epidemiol. 2012; 65: 989-995
- Urinary incontinence and behavioral symptoms are independent risk factors for recurrent and injurious falls, respectively, among residents in long-term care facilities.Arch Gerontol Geriatr. 2010; 50: 77-81
- Medication and fall injury in the elderly population; do individual demographics, health status and lifestyle matter?.BMC Geriatr. 2014; 14: 92
- The association between the number of prescription medications and incident falls in a multi-ethnic population of adult type-2 diabetes patients: The Diabetes and Aging Study.J Gen Intern Med. 2010; 25: 141-146
- Falls risk among a very old home-dwelling population.Scand J Prim Health Care. 2009; 27: 25-30
- Predictive validity of a modified fall assessment tool in nursing homes: Experience from Slovenia.Nurs Health Sci. 2009; 11: 430-435
- The incidence of falls among geriatric outpatients in relation to the number and types of drugs taken.Family Med Primary Care Rev. 2016; 18: 123-127
- The role of medication in falls among the elderly in a long-term care facility.Mount Sinai J Med. 1990; 57: 343-347
- Polypharmacy as a risk for fall occurrence in geriatric outpatients.Geriatr Gerontol Int. 2012; 12: 425-430
- Socioeconmic Differences in Injury Risks: A Review of Findings and a Discussion of Potential Countermeasures.WHO, Geneva2009
- Cognitive impairment is the major risk factor for development of geriatric syndromes during hospitalization: Results from the GIFA study.Dement Geriatr Cogn Disord. 2005; 20: 262-269
- Falls are associated with stroke, arthritis and multiple medications among community-dwelling elderly persons in Japan.Tohoku J Exp Med. 2013; 231: 299-303
- Low-intensity exercise and reduction of the risk for falls among at-risk elders.J Gerontol A Biol Sci Med Sci. 2004; 59: M1062-M1067
- Medication use and risk of falls.Pharmacoepidemiology & Drug Safety. 2002; 11: 97-104
- Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly.Am J Epidemiol. 1993; 137: 342-354
- Older individuals with diabetes have an increased risk of recurrent falls: Analysis of potential mediating factors: The Longitudinal Ageing Study Amsterdam.Age Ageing. 2012; 41: 358-365
- Predictors of falls in a multiethnic population of older rural adults with diabetes.J Gerontol A Biol Sci Med Sci. 2006; 61: 394-398
- Predictors of falls among elderly people—Results of 2 population-based studies.Arch Intern Med. 1989; 149: 1628-1633
- Falls in people with chronic obstructive pulmonary disease: An observational cohort study.Respir Med. 2011; 105: 461-469
- Understanding the relationship between walking aids and falls in older adults: A prospective cohort study.J Geriatr Phys Ther. 2015; 38: 127-132
- Risk factors for falling in community-dwelling older adults: Which of them are associated with the recurrence of falls?.J Nutr Health Aging. 2010; 14: 787-791
- Multiple medication use in older patients in post-acute transitional care: A prospective cohort study.Clin Interv Aging. 2014; 9: 1453-1462
- A classification tree for predicting recurrent falling in community-dwelling older persons.J Am Geriatr Soc. 2003; 51: 1356-1364
- Neuropsychological, physical, and functional mobility measures associated with falls in cognitively impaired older adults.J Gerontol A Biol Sci Med Sci. 2014; 69: 987-995
- Identifying older people at high risk of future falls: Development and validation of a screening tool for use in emergency departments.Emerg Med J. 2013; 30: 918-922
- Incidence and effects of polypharmacy on clinical outcome among patients aged 80+: A five-year follow-up study.PLoS One. 2015; 10: e0142123
- Associations between alcohol use, polypharmacy and falls in older adults.Nurs Older People. 2016; 28: 30-36
- Fall risk factors in community-dwelling elderly who receive Medicaid-supported home- and community-based care services.J Aging Health. 2011; 23: 682-703
- Factors associated with the elderly falling in intermediate care facilities.Drug Intell Clin Pharm. 1985; 19: 142-145
- Association between falls and high-risk medication use in hospitalized Asian elderly patients.Geriatr Gerontol Int. 2009; 9: 276-281
- Identification of high risk fallers among older people living in residential care facilities: A simple screen based on easily collectable measures.Arch Gerontol Geriatr. 2012; 55: 690-695
- Incidence and predicting factors of falls of older inpatients.Revista de Saude Publica. 2015; 49: 37
- Prevalence and related factors of falls among the elderly in an urban community of Beijing.Biomed Environ Sci. 2009; 22: 179-187
- Factors influencing falls in the frail elderly individuals in urban and rural areas.Aging Clin Exp Res. 2016; 28: 687-697
- Medical illnesses are more important than medications as risk factors of falls in older community dwellers? A cross-sectional study.Age Ageing. 2006; 35: 246-251
- Wearing slippers, falls and injury in residential care.Aust N Z J Public Health. 2004; 28: 180-187
- Risk factors for falls in older disabled women with diabetes: The Women's Health and Aging Study.J Gerontol A Biol Sci Med Sci. 2005; 60: 1539-1545
- Older women with diabetes have a higher risk of falls: A prospective study.Diabetes Care. 2002; 25: 1749-1754
- Laxative use and incident falls, fractures and change in bone mineral density in postmenopausal women: Results from the Women’s Health Initiative.BMC Geriatr. 2013; 13: 38
- Benzodiazepines and injurious falls in community dwelling elders.Drugs Aging. 2008; 25: 61-70
- Predisposing and precipitating factors for falls among older people in residential care.Public Health. 2002; 116: 263-271
- Medication for Alzheimer's disease and associated fall hazard: A retrospective cohort study from the Alzheimer's Disease Neuroimaging Initiative.Drugs Aging. 2014; 31: 125-129
- Psychotropic medications and falls in nursing homes: A cross-sectional study.J Am Med Dir Assoc. 2013; 14: 213-217
- Donepezil for the treatment of agitation in Alzheimer's disease.N Engl J Med. 2007; 357: 1382-1392
- Donepezil treatment of patients with severe Alzheimer's disease in a Japanese population: Results from a 24-week, double-blind, placebo-controlled, randomized trial.Dement Geriatr Cogn Disord. 2008; 25: 399-407
- Donepezil in patients with severe Alzheimer's disease: Double-blind, parallel-group, placebo-controlled study.Lancet. 2006; 367: 1057-1065
- Risk factors for falls in community-dwelling patients with Alzheimer's disease and dementia with Lewy bodies: Walking with visuocognitive impairment may cause a fall.Dement Geriatr Cogn Disord. 2009; 27: 139-146
- A double-blind, placebo-controlled multicentre study of memantine in mild to moderate vascular dementia (MMM500).Int Clin Psychopharmacol. 2002; 17: 297-305
- Memantine treatment in patients with moderate to severe Alzheimer disease already receiving donepezil: A randomized controlled trial.JAMA. 2004; 291: 317-324
- A 24-week randomized, controlled trial of memantine in patients with moderate-to-severe Alzheimer disease.Alzheimer Dis Assoc Disord. 2007; 21: 136-143
- Memantine treatment in mild to moderate Alzheimer disease: A 24-week randomized, controlled trial.Am J Geriatr Psychiatry. 2006; 14: 704-715
- Memantine treatment in patients with mild to moderate Alzheimer's disease already receiving a cholinesterase inhibitor: A randomized, double-blind, placebo-controlled trial.Curr Alzheimer Res. 2008; 5: 83-89
- Anticholinergic use and recurrent falls in community-dwelling older adults: Findings from the Health ABC Study.Ann Pharmacother. 2015; 49: 1214-1221
- Anticholinergic medication use and falls in postmenopausal women: Findings from the Women’s Health Initiative Cohort Study.BMC Geriatr. 2016; 16: 76
- Prevalence of risk factors for falls among elderly people living in long-term care homes.J Clin Gerontol Geriatr. 2016; 7: 99-103
- Factors related to falls among community dwelling elderly.Southeast Asian J Trop Med Public Health. 2013; 44: 906-915
- Factors associated with falls in the elderly: A community study.Age Ageing. 1981; 10: 141-146
- Risk factors for falls among the community-dwelling elderly in Korea.J Korean Acad Nurs. 2004; 34: 1483-1490
- Medication use, falls, and fall-related worry in older adults in the United States.Consult Pharm. 2016; 31: 385-393
- Associations of potentially inappropriate medicine use with fall-related hospitalisations and primary care visits in older New Zealanders: A population-level study using the updated 2012 Beers criteria.Drugs Real World Outcomes. 2015; 2: 137-141
- Application of the beers criteria to alternate level of care patients in hospital inpatient units.Can J Hosp Pharm. 2015; 68: 218-225
- Frequency of inappropriate drugs in primary care: Analysis of a sample of immobile patients who received periodic home visits.Age Ageing. 2011; 40: 66-73
- Quality use of medicines and health outcomes among a cohort of community dwelling older men: An observational study.Br J Clin Pharmacol. 2011; 71: 592-599
- Polypharmacy and falls in the middle age and elderly population.Br J Clin Pharmacol. 2006; 61: 218-223
- Type, number or both? A population-based matched case-control study on the risk of fall injuries among older people and number of medications beyond fall-inducing drugs.PLoS One. 2015; 10: e0123390
- Gastrointestinal dysfunction in Parkinson's disease.Lancet Neurol. 2015; 14: 625-639
- Opioid-induced constipation: Advances and clinical guidance.Ther Adv Chronic Dis. 2016; 7: 121-134
- Anticholinergics: Theoretical and clinical overview.Expert Opin Drug Saf. 2016; 15: 753-768
- The overlap between syncope and falls in the elderly.Postgrad Med J. 1997; 73: 635-639
Article info
Publication history
Published online: February 02, 2018
Footnotes
The authors declare no conflicts of interest.
This work was supported by the Clementine Brigitta Maria Dalderup Fund, which is an Amsterdam University Fund. The sponsor played no part in the design, methods, data collection, analysis and preparation of this paper. There is no conflict of interest in this regard.
Identification
Copyright
© 2018 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
