Some researchers believe that rising prescription medication use may explain a disturbing trend – an escalation in falls and fractures among older people – while others say it’s simply because we are living longer, and thus becoming frailer.
Earl Vickers (69) told The New York Times that for a while, even walking his dog felt hazardous.
“If another dog came toward us, every single time I’d end up on the ground,” recalled Vickers, a retired electrical engineer. “It seemed as if I were falling every other month. It was crazy.”
Most of those tumbles did no serious damage, though once he fell backwards and hit his head on a wall behind him. Another time, trying to break a fall, he broke two bones in his left hand.
So in 2022, he told the oncologist who had been treating him for prostate cancer that he wanted to stop the cancer drug he had been taking, off and on, for four years: enzalutamide (sold as Xtandi).
Among the drug’s listed side effects are higher rates of falls and fractures among patients who took it, compared with those given a placebo. His doctor agreed that he could discontinue the drug, and “I haven’t had a single fall since”, Vickers said.
Public health experts have warned of the perils of falls for older people for decades. In 2023, the most recent year of data from the Centres for Disease Control and Prevention, more than 41 000 Americans over 65 died from falls, an opinion article in JAMA Health Forum pointed out last month.
More startling, though, was another statistic: fall-related mortality among older adults has been climbing sharply.
The author, Dr Thomas Farley, an epidemiologist, reported that death rates from fall injuries among Americans over 65 had more than tripled over the past 30 years. Among those over 85, the cohort at highest risk, death rates from falls jumped to 339 per 100 000 in 2023, from 92 per 100 000 in 1990.
The culprit, in his view, is Americans’ reliance on prescription drugs.
“Older adults are heavily medicated, increasingly so, and with drugs that are inappropriate for older people,” Farley said. “This didn’t occur in Japan or in Europe.”
Yet that same 30-year period saw a flurry of research and activity to try to reduce geriatric falls and their potentially devastating consequences, from hip fractures and brain bleeds to restricted mobility, persistent pain and institutionalisation.
The American Geriatrics Society adopted updated Falls Prevention Guidelines in 2011. The CDC unveiled a programme called STEADI in 2019. The United States Preventive Services Task Force recommended exercise or physical therapy for older adults at risk of falling in 2012, 2018 and again last year.
“There’ve been studies and interventions and investments, and they haven’t been particularly successful,” said Dr Donovan Maust, a geriatric psychiatrist and researcher at the University of Michigan.
“It’s a bad problem that seems to be getting worse.”
But are prescription drugs driving that increase? Geriatricians and others who research falls and prescribing practices question that conclusion.
Farley, a former New York City health commissioner who teaches at Tulane University, acknowledged that many factors contribute to falls, including the physical impairments and deteriorating eyesight associated with advancing age; alcohol abuse; and tripping hazards in people’s homes.
“But there’s no reason to think any of them have got three times worse in the past 30 years,” he said, pointing to studies showing declines in other high-income countries.
The difference, he believes, is Americans’ increasing use of medications – like benzodiazepines, opioids, antidepressants and gabapentin – that act on the central nervous system.
“The drugs that increase falls’ mortality are those that make you drowsy or dizzy,” he said.
Problematic drugs are numerous enough to have acquired an acronym: FRIDs, or “fall risk increasing drugs”, a category that also includes various cardiac medications and early antihistamines like Benadryl.
Such medications play a major role, agreed Dr Thomas Gill, a geriatrician and epidemiologist at Yale University and a long-time falls researcher. But, he said, “there are alternative explanations” for the increase in death rates.
He cited changes in reporting the causes of death, for instance.
“Years ago, falls were considered a natural consequence of ageing and no big deal,” he said.
Death certificates often attributed fatalities among older people to ailments like heart failure instead of falls, making fall mortality appear lower in the 1980s and 1990s.
Today’s over-85 cohort may also be frailer and sicker than the oldest-old were 30 years ago, Gill added, because contemporary medicine can keep people alive for longer.
Their accumulating impairments, more than the drugs they take, could make them more likely to die after a fall.
Another sceptic, Dr Neil Alexander, a geriatrician and falls expert at the University of Michigan and VA Ann Arbor Healthcare System, argued that most doctors have come to understand the dangers of FRIDs and prescribe them less often.
“Message delivered,” he said. Given the alarms sounded about opioids, about benzodiazepines and related drugs, and especially about opioids and benzos together, “a lot of primary care doctors have heard the gospel”, he said. “They know not to give older people Valium.”
Moreover, prescriptions for some fall-related drugs have already declined or hit plateaus, even as death rates because of falls have risen. Medicare data show lower prescription opioid use beginning a decade ago, for example. Benzodiazepine prescriptions for older patients have slowed, Maust said.
On the other hand, the use of antidepressants and of gabapentin has increased.
Whether or not medication use outweighs all other factors, “nobody disputes that these agents are overused and inappropriately used” and contribute to the troubling increase in fall death rates among seniors, Gill said.
Thus, the ongoing campaign for “de-prescribing” – stopping the medications whose potential harms outweigh their benefits, or reducing their dosage.
“We know a lot of these drugs can increase falls by 50% to 75% in older patients,” said Dr Michael Steinman, a geriatrician at the University of California-San Francisco, and co-director of the US Deprescribing Research Network, established in 2019.
“It’s easy to start meds, but it often takes a lot of time and effort to have patients stop taking them,” he said.
Harried doctors may pay less attention to drug regimens than to health issues that seem more pressing, and patients can be reluctant to give up pills that seem to help with pain, insomnia, reflux and other common age-related complaints.
The Beers Criteria, a directory of drugs often deemed inadvisable for older adults, recently published recommendations for alternative medications and non-pharmacological treatments for frequent problems.
Cognitive behavioural therapy for sleeplessness. Exercise, physical therapy and psychological interventions for pain.
“It’s a real tragedy when people have this life-altering event,” Steinman, co-chair of the Beers panel on alternatives, said of falls. He urged older patients to raise the issue of FRIDs themselves, if their doctors haven’t.
“Ask, ‘Do any of my medications increase the risk of falls? Is there an alternative treatment?’” he suggested. “Being an informed patient or caregiver can put this on the agenda. Otherwise, it might not come up.”
The New York Times article –Why Are More Older People Dying After Falls? (Restricted access)
See more from MedicalBrief archives:
High mortality risk after hip breaks in elderly – Canadian analysis
Minor lifestyle changes can cut hip fracture risk by 45% – Australian study
Daily aspirin increases risk of falls in the elderly – ASPREE trial