Psychotropic Medications and Falls Risk

Older adults with dementia are two to eight times more likely to fall than their cognitively intact peers. An estimated two-thirds of cognitively impaired older adults fall every year. While factors such as attention deficits and gait and balance problems clearly contribute to the risk of falling in older adults, there are numerous other factors to consider. For instance, in patients with dementia, psychotropic medications may affect falls risk. While the association between psychotropic medications and the risk of falling has been unclear, an important study published in the June issue of the Journal of the American Geriatrics Society sheds new light on this issue and highlights the need for additional research in this area. Cholinesterase inhibitors (eg, acrine, donepezil, rivastigmine, galantamine) and memantine, an N-methyl-D-aspartate receptor antagonist, are commonly prescribed for older adults with dementia. Yet despite their widespread use, “little is known about the impact of these medications on gait, falls, and fall-related adverse events,” notes Dae Hyun Kim, MD, MPH, Harvard Medical School, Boston, MA, and coauthors in the study. While some research suggests that cholinesterase inhibitors may lower falls risk by improving gait, balance, attention, and executive function, Kim and colleagues note that a recent, large, population-based cohort study and several case reports suggest that these drugs may actually increase the risk of falls.

To put all of the data into context, Kim and colleagues conducted a systematic review and meta-analysis of more than 50 placebo-controlled, randomized trials of cholinesterase inhibitors and memantine in seniors with dementia or mild cognitive impairment. The results of their meta-analysis suggest that while cholinesterase inhibitors boost the risk of syncope, they have no statistically significant effect on the incidence of falls, fractures, or related injuries. “However, due to small numbers and possible under-reporting of events, we cannot exclude the possibility of small benefits or harms,” the authors write, noting that a double-blind, placebo-controlled randomized trail examining the effect of the cholinesterase inhibitor donepezil on gait and balance in adults with mild cognitive impairment (NCT00934531) is currently underway and may help clarify matters. Kim and colleagues’ meta-analysis found no link between memantine and increased risks of syncope, falls, or accidental injury. In fact, their study suggested a possible reduction in risk of fracture with the drug; however, they note that only a small number of studies are available for review, leading to the possibility that the drug might result in “small benefits or harms” that did not manifest in the analysis. “Considering the public health impact of fall-related adverse events and the potential causal role of medications in such events among older adults with cognitive impairment, [falls and related] events should be routinely included in trial reports,” Kim and colleagues recommend.

“Furthermore, more high-quality observational research is warranted to evaluate the impact of these agents on fall-related adverse events in a more representative population,” they add, pointing out that the majority of studies to date have examined the drugs’ effects on older adults living in the community as opposed to long-term care facilities. In 2010, the American Geriatrics Society and the British Geriatrics Society released updated falls prevention guidelines (https://bit.ly/AGS-BGS_Fall-Prevention-2010), which advise healthcare professionals to review the medications that their elderly patients take (previous guidelines recommended a medication review only for those taking four or more drugs) and to cut back on medications that increase the risk of falling whenever possible. More complete information regarding the risks and benefits of commonly prescribed dementia medications will make such reviews far more effective for cognitively impaired seniors—a subgroup at particularly high risk of falling.