Falls are a leading cause of death in older adults, and can cause numerous health complications. Prescribing in the community is important to protect the health of the frail and vulnerable, just as the use of deprescribing can be used for the same purpose. In response to the significant health and financial burden on patients and healthcare systems brought about by falls, Lee et al (2021) carried out a systematic review and meta-analysis to examine the deprescribing of fall-risk-increasing drugs (FRIDs) for the prevention of falls and associated complications. Deprescribing such medications can be common practice for falls prevention, despite an apparent scarcity of robust evidence to support this move. In the community, falls are common, and it is always a consideration that patient medication should be reviewed regularly to look at risks and requirements.
Despite there being limited evidence of effectiveness, deprescribing FRIDs is common practice and typically included in both multifactorial and single-intervention strategies. The justification is based on observational studies that suggest that certain medications are linked to an increased falls risk, as well as some randomised controlled trials (RCTs) showing that medication management interventions (including those with a broader focus of reducing polypharmacy and/or potentially inappropriate prescribing) may reduce the risk of falls.
FRIDs include antihypertensives, antiarrhythmics, anticholinergics, antihistamines, sedatives-hypnotics, antipsychotics, antidepressants, opioids and non-steroidal anti-inflammatory drugs (de Vries et al, 2018; Seppala et al 2018a; 2018b). The mechanisms are not fully understood; however, it is speculated that these drugs may influence falls risk by adversely affecting the cardiovascular or central nervous system (such as through orthostatic hypotension, bradycardia, sedation, sleep disturbance, confusion, dizziness) (de Vries et al 2018; Seppala et al 2018a; 2018b).
The study
Lee et al (2021) used well-known databases, and inclusion criteria included RCTs of FRID withdrawal compared with usual care evaluating the rate of falls, incidence of falls, fall-related injuries, fall-related fractures, fall-related hospitalisations or adverse effects related to the intervention in adults aged ≥65 years. Five trials including 1305 participants met the eligibility criteria. Deprescribing FRIDs was actually found not to change the incidence of falls, nor the rate of fall-related injuries over a follow-up period of 6–12 months. No trials evaluated the impact of deprescribing FRIDs on fall-related fractures or hospitalisations.
Lee et al (2021) concluded that there is a paucity of robust high-quality evidence to support or refute that a FRID deprescribing strategy alone is effective for the prevention of falls or fall-related injury in older adults. This is extremely important in the recognition that some medications that are useful for other health purposes may be being needlessly discontinued to prevent falls while increasing risks of other health concerns, and deprescribing should, therefore, be practised with caution.
Owing to low-quality evidence, the authors noted that it remains unclear whether deprescribing FRIDs as a single intervention leads to any appreciable clinically important benefit or harm. Their best-effect estimates for falls rate and incidence are centred around no appreciable difference. Although seemingly logical to assume, Lee et al (2021) stated that reducing isolated risk factors may not necessarily lead to a reduction in falls and fall-related complications.
Medications may only have conditional or contributory causality to falls. It may be that medication-related interventions work best in combination with other interventions or only in specific contexts. Falls prevention is multifactorial and the nature and combination of risks is complex. Therefore, medication changes may contribute to falls reduction, but only in combination with other strategies to reduce risk, which is something that requires further investigation.
Recommendations
The research outcomes bring about several questions regarding the presumption that deprescribing FRIDs is effective as an isolated falls prevention strategy. Given the amount of resources being invested in falls prevention initiatives around the world due to the relation of falls to significantly worsening health outcomes, complex and chronic illness and mortality rates, the researchers have made several recommendations. Lee et al (2021) recommended that clinicians and organisations examine the strength of evidence supporting their activities, whether they are cost effective and whether resources are being appropriately prioritised to those interventions shown to provide the most value. They also recommended that this advice be applied to what is being required of healthcare organisations in national accreditation standards, in order to optimise use of limited healthcare resources.
It is also important for clinicians and policy makers to consider the lack of strong evidence for deprescribing FRIDs as an isolated intervention for the specific purpose of reducing falls, especially in patients who may be very reluctant or who have strong indications for specific FRIDs (Lee et al, 2021). FRIDs reduction is just one of many possible interventions that require consideration for falls prevention. Along with prescribing medications, deprescribing is also a skill requiring much consideration and critique, with the potential for harm as well as benefit. The results shown by Lee et al (2021) clearly demonstrated the requirement for a comprehensive and individualised approach to falls prevention. Multicomponent interventions are ideal, they noted (Lee et al, 2021), but interventions may need to be prioritised depending on time, resources and context.
However, while Lee et al (2021) identified insufficient evidence supporting or refuting the deprescribing of FRIDs for falls prevention, they pointed out that their results do not mean that clinicians should avoid deprescribing FRIDs. There may be many other reasons to deprescribe these medications, such as for the purpose of avoiding adverse drug events, improving cognition, increasing medication adherence and making drug costs savings.