Do Antidepressants Increase Fall Risk In The Elderly?

Do Antidepressants Increase Fall Risk In The Elderly?

By Brian McCurdy, Senior Editor

Elderly patients can be at risk for falls and a recent study in the American Journal of Geriatric Psychiatry finds that antidepressant use can cause gait disturbances in older people.    

The study looked at 1,998 people over 60 and measured gait during single and dual task walking with a 4.88 m walkway. In the unadjusted models, depressive symptoms and antidepressant use were associated with gait deficits. After adjusting for covariates, the study notes antidepressant use was associated with reduced gait speed and stride length in single and dual task walking while depressive symptoms themselves were not associated with any deficits.    

Michael DeBrule, DPM, calls the study “a good reminder for podiatrists to always be on the lookout for medications that can contribute to fall risk like antidepressants, anticonvulsants, antihypertensives, etc.”    

In his practice, Doug Richie Jr., DPM, FACFAS, has observed the same abnormalities described in the study: shortened stride length, decreased walking speed and increased double support.    

“Podiatric physicians may be the first medical specialists likely to detect these changes because they often perform gait analysis on their patients,” says Dr. Richie, an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif.    

Dr. DeBrule has not encountered a fall risk patient for whom he suspected an antidepressant was the cause. In the past, he has referred some patients back to their primary care physicians for antihypertensive side effects like orthostatic hypertension.    

To prevent falls in patients, Dr. DeBrule will screen them with a numeric fall assessment tool like the Morse Fall Scale. After identifying a patient as high risk and finding there is a questionable medication, he says the podiatrist could call a pharmacist and/or the patient’s primary care physician to discuss further.    

The preventive strategies for falls in patients on antidepressants would be very similar to those interventions that have been designed and tested for other patient populations at risk for falling, according to Dr. Richie. As he notes, the study says patients being treated for depression have other comorbidities that are associated with an increased risk of falling. Dr. Richie emphasizes the importance of communication with the primary care doctor or specialist who prescribed the antidepressant medication if the podiatric physician noted a gait disturbance that could increase the risk of falls.    

“While it is unclear how antidepressants cause a gait disturbance and increased falls risk, it must be assumed that this is a central mediated mechanism which cannot be directly modified by the podiatric physician,” says Dr. Richie.    

Dr. Richie also cites several proven podiatric interventions for falls, including footwear selection, foot strengthening, foot orthoses (not ankle-foot orthoses) and patient education. He says these can have a positive effect on patients at risk for falls, including those taking antidepressant medication.    

For patients who need antidepressants but are at risk for falls, Dr. DeBrule suggests the primary care doctor can change the medicine to a lower dosage, prescribe a different medication or attempt non-pharmacological therapy if appropriate. Physical therapy may be a good option for patients with depression, says Dr. DeBrule, who is in private practice at Midwest Podiatry Centers in Richfield, Minn.    

Given that the study notes the medication, not the depression itself, seems to cause the gait disturbance, Dr. Richie postulates that withdrawing the medication would appear to have a benefit. He cautions that one should leave the risks for withdrawing this medication to the primary care provider to evaluate.

New Agent Approved For MRSA

By Brian McCurdy, Senior Editor

Podiatric physicians have a new option to treat acute bacterial skin and skin structure infections as the Food and Drug Administration has approved a new intravenous treatment.    

Dalbavancin (Dalvance, Durata Therapeutics) is indicated for infections caused by bacteria including Staphylococcus aureus (including methicillin-susceptible and methicillin-resistant strains) and Streptococcus pyogenes, according to the FDA. The FDA cites two clinical trials of a total of 1,289 adults with acute bacterial skin and skin structure infections in which dalbavancin was as effective as vancomycin.    

Warren Joseph, DPM, calls dalbavancin “a fascinating drug in terms of its pharmacokinetics.” He says one would administer it in only two IV injections: 1 g on the first day and then 500 mg on day seven. The weekly dosing makes it easy to administer but raises some significant questions such as whether one could use the agent in hospitals or physicians’ offices. In addition, although the price of dalbavancin is as yet unknown, it may be very high, perhaps thousands of dollars, speculates Dr. Joseph, a Fellow of the Infectious Diseases Society of America.    

“At that price, what hospital formulary is going to carry it when they can get vancomycin for a few dollars? Can hospitals/EDs get reimbursed for it and by whom?” asks Dr. Joseph.    

The long half-life of this drug raises a question about possible adverse events for Dr. Joseph. Although the drug appears safe in the clinical trials, what will happen if the patient does experience an adverse event, posits Dr. Joseph. If the drug remains in the patient’s system for over a week, he wonders if there is any way to eliminate the drug to resolve the adverse event.    

Since the drug has been approved under the FDA’s Acute Bacterial Skin and Skin Structure Guidance, Dr. Joseph assumes that diabetic foot infections were excluded from the clinical trial. He says it remains to be seen how many of the treated infections were in the lower extremity and how many patients had diabetes.    

“As with any new drug, there are questions that remain unanswered and we will only know about these after the agent is in more generalized use,” says Dr. Joseph.

How Effective Is Tapentadol In Relieving Diabetic Neuropathic Pain?

By Brian McCurdy, Senior Editor

Extended release tapentadol (Nucynta, Janssen Pharmaceuticals) may be effective in managing moderate to severe chronic pain in patients with diabetic peripheral neuropathy, according to a recent study in Diabetes Care.    

As part of the randomized study, 166 patients received 100 to 250 mg of tapentadol and 152 patients received a placebo. The study’s primary endpoint was mean change in average pain intensity from the start to week 12. The study authors noted that tapentadol was beneficial in reducing neuropathic pain and patients tolerated it well.    

Although he feels tapentadol could be promising for patients with diabetic neuropathy, Andrew Meyr, DPM, cautions that tapentadol as well as any other number of interventions for painful diabetic neuropathy are primarily symptom-managing agents and do not address the underlying root cause of the complaint.    

“Any time I use pharmacotherapy for the treatment of this condition, I am careful to explicitly point out to the patient that in no way is this a cure for the diabetic neuropathy but rather something that may tone down the symptoms a bit,” says Dr. Meyr, an Associate Professor in the Department of Podiatric Surgery at Temple University School of Podiatric Medicine. “I tell them that the neuropathy is still very much there but perhaps (they) won’t feel as much pain associated with it.”    

Dr. Meyr adds that the reduction of pain for patients taking tapentadol in the study is “somewhat modest.” These patients started with a pain rating of about 7/10, which decreased to about 4/10, a number that Dr. Meyr notes is still considered “moderate” pain based on the World Health Organization’s analgesic pyramid.   

“So at least in my world, that is still a patient who is complaining about pain albeit less than (he or she) had before. This is a good example of a statistically significant difference that may not be as clinically significant,” points out Dr. Meyr.    

In regard to side effects of tapentadol, Dr. Meyr notes that the study’s nausea rate of over 20 percent and vomiting rate of over 10 percent are “not insignificant.” He says some other studies of tapentadol have shown similar rates of side effects, some even a bit higher.

In Brief

Valeant Pharmaceuticals North America announced that the Food and Drug Administration has approved a New Drug Application for efinaconazole 10% topical solution (Jublia). The company notes Jublia is the first topical triazole approved for the treatment of onychomycosis of the toenails.