Mental Domain

Falls Prevention Literature Review

Neyens JCL, Dijcks BPJ, Twisk J, et al. A multifactorial intervention for the prevention of falls in psychogeriatric nursing home patients, a randomized controlled trial (RCT). Age and Ageing 2009;38:194-199.
Variable Studied: Mental resident risk factors.
Setting-Situation: Psychogeriatric wards from 12 nursing homes in the Netherlands.
Sample Size: N=518 patients. Intervention group: N=249; mean age=82.1, 65% female. Control group: N=269; mean age=83.3, 71% female.
Study Design: Cluster randomized controlled 12-month trial. Risk factors: psych geriatric conditions, fall history, medication intake, mobility, and use of assistive and protective aids. Interventions: general medical assessment and additional specific falls risk evaluation tool applied by a multidisciplinary fall prevention team. Control: usual care. Outcome: falls.
Results: There were 355 falls in 169.5 patient-years (2.09 falls per patient per year) in the intervention group and 422 falls in 166.3 patient-years (2.54 falls per patient per year) in the control group. Intention-to-treat analysis with adjustment for ward-related and patient-related parameters, and intracluster correlation, showed that the intervention group had a significantly lower mean fall incidence rate than the control group (rate ratio =0.64, 95% CI=0.43-0.96, p=0.029). Subgroup analyses showed that fall risk declined further as patients participated longer in the intervention program.
Conclusions: Introduction of a structured multifactorial intervention to prevent falls in psychogeriatric nursing home patients significantly reduces the number of falls. This reduction is substantial and of high clinical relevance.

Ensrud KE, Blackwell TL, Mangione CM, et al. Central nervous system-active medications and risk for falls in older women. Journal of the American Geriatric Society 2002;50:1629-1637.
Variable Studied: Medical treatment risk factors; central nervous system-active medication.
Setting-Situation: Four community clinical centers in Baltimore, Maryland; Portland, Oregon; Minneapolis, Minnesota; and Monongahela Valley, Pennsylvania.
Sample Size: N=8,127 community-dwelling women participating in fourth examination of the Study of Osteoporotic Fractures between 1992 and 1994; age=65+.
Study Design: Prospective cohort study. Risk factors: central nervous system (CNS)-active medications, including benzodiazepines, antidepressants, anticonvulsants, and narcotics. Outcome: falls.
Results: During an average followup of 12 months, 2,241 women (28%) reported falling at least once, including 917 women (11%) who experienced two or more falls. Compared with nonusers, women using benzodiazepines (multivariate odds ratio [MOR]=1.51, 95% 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 subsequent year. Among benzodiazepine users, women using short-acting drugs (MOR=1.42, 95% CI=0.98-2.04) and those using long-acting drugs (MOR=1.56, 95% CI=1.00-2.43) appeared to be at greater risk for frequent falls than nonusers. No evidence was found to suggest that women using selective serotonin-reuptake inhibitors had a lower risk for frequent falls than those using tricyclic antidepressants. No association was found between narcotic use and falls (MOR=.99, CI=.68-1.43).
Conclusions: Community-dwelling older women taking CNS-active medications, including benzodiazepines, antidepressants, and anticonvulsants are at increased risk of frequent falls. Minimizing use of these CNS-active medications may decrease risk of future falls. Fall risk in women taking benzodiazepines is marginally decreased by use of short-acting preparations. Preferential use of selective serotonin-reuptake inhibitors is unlikely to reduce fall risk in older women taking antidepressants.

Leipzig, RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs. Journal of the American Geriatric Society 1999;47(1):30-39.
Variable Studied: Mental treatment risk factors; psychotropic drugs.
Setting-Situation: Systematic evaluation of sedative/hypnotic, antidepressant, or neuroleptic use with falling in people age 60 and older.
Sample Size: N=40 studies. None were randomized controlled trials.
Study Design: Fixed-effects meta-analysis of English-language articles in MEDLINE® (1966-March 1996) indexed under "accidents" or "accidental falls" and "aged" or "age factors." Risk factors: psychotropic drugs. Outcome: falls.
Results: For one or more falls, the pooled odds ratio (OR) (95% confidence interval [CI]) was 1.73 (1.52-1.97) for any psychotropic use; 1.50 (1.25-1.79) for neuroleptic use; 1.54 (1.40-1.70) for sedative/hypnotic use; 1.66 (1.4-1.95) for any antidepressant use (mainly tricyclics); 1.51 (1.14-2.00) for only tricyclic antidepressant use; and 1.48 (1.23-1.77) for benzodiazepine use, with no difference between short- and long-acting benzodiazepines. Increased falls occurred in patients taking more than one psychotropic drug.
Conclusions: There is a small, but consistent, association between the use of most classes of psychotropic drugs and falls.

Thapa PB, Gideon P, Fought RL, et al. Psychotropic drugs and risk of recurrent falls in ambulatory nursing home residents. American Journal of Epidemiology 1995;142(2):202-211.
Variable Studied: Mental treatment risk factors; psychotropic medications.
Setting-Situation: Nursing homes.
Sample Size: N=282 ambulatory residents; age=65 years and older.
Study Design: Prospective cohort study. Risk factors: symptoms of dementia (cognitive impairment and behavior problems), depression, psychotropic drug use. Outcome: risk of falls.
Results: During followup, 111 residents had 2 or more falls, an incidence rate of 54.9 recurrent falls per 100 person-years. With the use of Cox proportional hazards modeling, authors found incidence density ratios (95% confidence intervals [CIs]) showing that the following risk factors were independently associated with recurrent falls: age ≥75 years (1.66 [1.01-2.72]); ≥4 assisted activities of daily living (1.94 [1.09-3 47]); middle (2.08 [1 20-3.61]) and upper (2.54 [1.44-1.49]) tertiles of balance impairment; fall in 90 days preceding assessment (2.01 [1.32-3.06]); and upper tertile of behavior problems (1.65 [1.03-2.64]). Rate of recurrent falls increased tenfold as number of risk factors increased from 0 to 5 (21.4 to 231.5 per 100 person-years, p≤0.0002). After controlling for symptoms of dementia, depression, and other fall risk factors, the incidence density ratio for recurrent falls in baseline regular psychotropic drug users (n=178) compared with nonusers (n=104) was 1.97 (95% Cl 1.28-3.05). Within groups defined by number of other independent fall risk factors present, regular psychotropic users had a recurrent fall rate that was greater than that for nonusers: 44.1 versus 22.9 per 100 person-years (p=0.03) in the low-risk (≤2 factors) group and 98.7 versus 64.3 (p=0.08) in the high-risk (>2 factors) group.
Conclusions: Risk of recurrent falls for regular psychotropic drug users was 36%, which suggests optimal management of psychopharmacotherapy is an essential component of fall prevention programs for ambulatory nursing home residents.

Mustard CA, Mayer T. Case-control study of exposure to medication and risk of injurious falls requiring hospitalization among nursing home residents. American Journal of Epidemiology 1997;145(8):738-745.
Variable Studied: Mental treatment risk factors; antipsychotic medication: anxiolytics/sedatives/hypnotics.
Setting-Situation: Nursing home data collected from April 1987 to March 1992.
Sample Size: N=1,488 cases and matched controls; age=86% >75 years.
Study Design: Case-control study. Risk factors: types of medications used, including psychotropics; resident characteristics. Outcomes: injurious fall, injury consequent to a fall that resulted in admission to the hospital for treatment.
Results: Nearly 1,600 first injurious falls (1,560) occurred in 14,744 residents. Two medication classes were identified in which prescriptions dispensed in the previous 30 days were associated with elevated risk of injurious fall: antipsychotic agents (odds ratio [OR]=1.31, 95% confidence interval [CI] 1.06-1.61) and anxiolytics/sedatives/hypnotics (OR=1.31, 95% CI 1.09-1.68). An unexpected protective effect was associated with use of inotropic agents (OR=0.69, 95% CI 0.54-0.89).
Conclusions: These results support the hypothesis that psychotropic medications are independent risk factors for injurious falls in nursing home settings.

Hartikainen S, Lonnroos E, Louhivuori K. Medication as a risk factor for falls: critical systematic review. Journal of Gerontology 2007;62A(10):1172-1181.
Variable Studied: Mental treatment risk factors; psychotropic medications.
Setting-Situation: Various settings.
Sample Size: N=29 (28 observational studies and 1 randomized controlled trial). N=70-132,873 participants.
Study Design: Critical systematic review of English articles in Medline (1996-2004) indexed under "falls" or "accidental falls" and "pharmaceutical preparations" or specific groups of drugs. Risk factors: types of medications used, including psychotropics; resident characteristics. Outcomes: fall in 22 studies and fracture in 7 studies.
Results: The main drugs associated with increased risk of falling were psychotropics: benzodiazepines, antidepressants, and antipsychotics. Antiepileptics and drugs that lower blood pressure were weakly associated with falls.
Conclusions: Central nervous system agents, especially psychotropics, are associated with increased risk of falls. Quality of observational studies needs to be improved; many lack a clear definition of a fall, target medicines, or prospective followup. Many drugs commonly used by older persons are not systematically studied as risk factors for falls.

Ray WA, Thapa PB, Gideon P. Benzodiazepines and the risk of falls in nursing home residents. Journal of the American Geriatric Society 2000;48(6):682-685.
Variable Studied: Mental treatment risk factors; benzodiazepines.
Setting-Situation: Nursing homes.
Sample Size: N=2,510 residents from 53 nursing homes in Tennessee.
Study Design: Historical cohort study. Risk factors: benzodiazepines, resident characteristics. Outcome: rate of falls.
Results: After adjustment for differences in resident characteristics, benzodiazepine users had a 44% increased rate of falls (adjusted rate ratio 1.44). Adjusted rate ratio increased from 1.30 (1.12-1.52) for dose equivalent to ≤2 mg of diazepam, to 2.21 (1.89-2.60, p<.001) for a dose of >8 mg. Rate of falls was greatest 7 days after benzodiazepine was started but remained elevated after the first 30 days of therapy. Drugs with elimination half-lives of <12, 12-23, and ≥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). 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.

Shaw FE, Bond J, Richardson DA, et al. Multifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randomized controlled trial. British Medical Journal 2003 Jan 11;326:73.
Variable Studied: Mental treatment to reduce risk.
Setting-Situation: Emergency department
Sample Size: N=274 cognitively impaired older people (age 65 and older) presenting to accident and emergency department after a fall (130 intervention; 144 controls).
Study Design: Randomized controlled trial. Risk factors: cognitive impairment and dementia. Interventions: multifactorial assessment and intervention after a fall in older patients with cognitive impairment and dementia. Control: assessment followed by conventional care (control group). Primary outcome: fall in year after intervention. Secondary outcomes: number of falls, time to first fall, injury rates, fall-related attendance at accident and emergency department, fall-related hospital admissions, and mortality.
Results: No significant difference was found between intervention and control groups in the proportion of patients who fell during first year's followup (74% (96/130) and 80% (115/144), relative risk ratio 0.92, 95% confidence interval 0.81 to 1.05). No significant differences were found between groups for secondary outcome measures.
Conclusions: Multifactorial intervention was not effective in preventing falls in older people with cognitive impairment and dementia presenting to the accident and emergency department after a fall.

Current as of February 2010
Internet Citation: Mental Domain: Falls Prevention Literature Review. February 2010. Agency for Healthcare Research and Quality, Rockville, MD.