Rethinking medicines part 3: fall-risk-increasing medicines

Clinical scenario

Rose, 85, has had two falls over the past three months, including one soon after starting oxybutynin for urinary incontinence (see part 2). She also takes a benzodiazepine at night for sleep and an antihypertensive, both of which she has been taking for years without a recent medication review. Rose is worried about falling again and has started reducing her usual activities, including going out to see friends.

What is the link between medicines and falls?

Falls are common in older people and can have serious consequences, including fractures, hospitalisation, and loss of independence. Medicines can contribute to falls through effects such as sedation, dizziness, impaired balance and postural hypotension.

Regular medication review is important to ensure that the benefits of medicines continue to outweigh their potential harms, particularly after a significant health event. A fall can be an important trigger for medication review and, where appropriate, deprescribing.

What does the guideline suggest?

Deprescribing should be considered where adverse effects or interactions outweigh the potential benefits. For older people at risk of falls, this is particularly relevant to fall-risk-increasing medicines.

The new Australian deprescribing guideline (available at deprescribing.com) provides deprescribing suggestions for several medicine classes that may contribute to falls, including:

• Benzodiazepines: consider offering deprescribing to older people taking benzodiazepines as the potential harms, including falls, sedation and dependence generally outweigh the benefits, except in special circumstances.

• Antipsychotics: consider deprescribing when adverse effects or drug interactions outweigh potential benefits, including in people experiencing recurrent falls.

• Antihypertensives: consider deprescribing when adverse effects may outweigh benefits, particularly in the presence of orthostatic hypotension or recurrent falls. Blood pressure targets should be individualised in older people and may be less stringent, balancing the potential benefits of preventing cardiovascular events against the risks of adverse effects.

• Opioids: consider deprescribing when there is no ongoing indication or when adverse effects or interactions outweigh the benefits, such as when chronic pain is adequately controlled with non-pharmacological approaches.

• Diabetes medicines: glycaemic targets should be regularly reviewed, particularly in the context of frailty, comorbidities, hypoglycaemia or changes in health status. The guideline supports individualised treatment goals and consideration of deprescribing when the potential harms of continued treatment outweigh the benefits.

• Genitourinary anticholinergics: consider deprescribing in older people with cognitive impairment, delirium, dementia or a high risk of falls, as the potential harms may outweigh the benefits. Also consider whether urinary symptoms may be caused or worsened by another medicine, to avoid an inappropriate prescribing cascade. Genitourinary anticholinergics can add to the overall anticholinergic burden, increasing the risk of adverse effects when combined with other anticholinergics.

Coming up

The next article in the Rethinking medicines series will explore the cognition and medicine burden.

Dr Xisco Reus and Professor Christopher Etherton-Beer are medical practitioners. Dr Amanda Quek and Associate Professor Amy Page are pharmacists. They are all researchers at The University of Western Australia.

Read other clinical stories here
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