Medication and falls risk in the Older Person

Reproduced from BHPS at this link

This classification has been based upon a review of the clinical evidence of medicines most commonly implicated in falls.22 The list is not meant to be fully comprehensive but intended to raise awareness. Advice is provided on how medicines should be stopped (deprescribed).

 

Highest risk

Guidance

Antidepressants

Avoid tricyclic antidepressants especially with high anti-muscarinic activity e.g. amitriptyline. SSRIs are associated with a reduced incidence of side effects. Trial of gradual antidepressant withdrawal should be attempted after 6 –12 months.

Antipsychotics including atypicals

 

Risk of hypotension is dose related reduced by the ‘start low go slow approach.’ Atypical antipsychotics have similar falls risk to traditional ones. Attempted withdrawal MUST always be gradual. Prochlorperazine is often inappropriately prescribed for dizziness and causes drug induced Parkinson’s disease

Anti-muscarinic drugs (Anticholinergics)

Oxybutynin may cause acute confusional states in the elderly especially those with pre-existing cognitive impairment

Benzodiazepines & Hypnotics

 

Dose reduction is beneficial if withdrawal is not possible . Avoid long acting benzodiazepines. Newer hypnotics are associated with reduced hangover effects but all licensed for short-term use only

Dopaminergics used in Parkinson’s disease

Sudden excessive daytime sleepiness can occur with levodopa and other dopamine receptor agonists. Dose titration is important in initiation due risk of inducing confusion. Maintenance doses may need to be reduced with aging

Moderate risk

 

Anti-arrhythmics

Dizziness and drowsiness are possible signs of digoxin toxicity. Risks of toxicity are greater in renal impairment or in the presence of hypokalaemia. Flecainide has a high risk for drug interactions and can also cause dizziness

Anti-epileptics

High risk for potential drug interactions. Important side effects include: Dizziness, drowsiness and blurred vision (dose related)

Opiate analgesics

Drowsiness is common with initiation, but tolerance to this is usually seen within 2 weeks of continuous treatment. Drowsiness is rare with codeine unless used in combination with other CNS drugs. Confusion reported with tramadol

Antihistamines

Somnolence may affect up-to 40% of patients with older antihistamines. The newer antihistamines cause less sedation and psychomotor impairment. Risk of hypotension with cinnarizine is a dose related side effect

Alpha-blockers

Doses used for treatment of BPH less likely to cause hypotension than those required to treat hypertension

ACEI/ARB

Risk of hypotension is potentiated by concomitant diuretic use. Incidence of dizziness affects twice as many patients with heart failure than hypertension

Diuretics

Postural hypotension, dizziness and nocturia are problems seen in the elderly. Diuretics should not be used in the long-term treatment of gravitational oedema

Beta-blockers

 

Postural hypotension and can affect up to 10% of patients. Can accumulate in renal impairment and therefore dose reduction is often necessary

Lower risk

 

CCBs

Incidence of dizziness low especially for once daily dihydropyridine CCBs

Nitrates

Advise patient to sit when using GTN spray or tablets

Oral anti-diabetic drugs

Dizziness due to hypoglycaemia, but usually avoidable. Avoid long acting sulfonylureas e.g. chlorpropamide.

PPIs & H2 Antagonists

Avoid cimetidine in polypharmacy patients as high risk of drug interactions, and causes confusion.