Evidence
Alert

Care home residents on multiple medications have an increased risk of falling

Falls among residents in UK care homes are commonplace. A new study examined whether multiple medications and drugs that act on the brain may contribute to the risk.

The research, which included 84 UK care homes, found that residents taking multiple medicines had an increased risk of falling. Risk was also increased with a regular prescription for antidepressants or benzodiazepines (sedative drugs).

Two-thirds of the residents in the study were living with dementia. Researchers suggest that care homes should emphasise non-drug approaches such as massage, music or art therapies. These interventions could help residents with depression and common symptoms of dementia such as agitation or sleep disturbance.

What’s the issue?

When older people fall, they can sustain serious and life-threatening, or life-changing, injury. Those living in care homes are three times more likely to fall than those living in their own homes.

One explanation could be the medication commonly taken by care home residents. Combinations of drugs could increase risk, as could medicines that act on the brain. This includes medications for depression, anxiety, and the behavioural and psychological symptoms of dementia.

What’s new?

This study is a more detailed analysis of the (as yet unpublished) Falls in Care Homes (FinCH) study in which researchers analysed care and medication records of residents at 84 UK care homes.

They included 1,655 people with an average age of 85. Two-thirds of the participants were women.

Two-thirds of those surveyed had dementia and on average, each resident was taking six different drugs. About half (816) took regular medications that act on brain.

The study found that the number of regular drugs prescribed was an independent risk factor for falling. Taking more than one regular drug that acts on the brain, such as an antidepressant or sedative, also increased risk. However, the study did not find a link between falls and antipsychotic drugs.

Over a three-month period, the study found that:

  • almost one in three residents (519 or 31%) had one or more falls
  • the risk was higher in those taking antidepressants and sedatives
  • older residents were more likely to fall than their younger counterparts
  • men had more falls than women
  • residents with dementia had 75% more falls than those without dementia.

Even when age, gender and a diagnosis of dementia were taken into account, the link between medication and falls remained.

For every additional drug prescribed, the chances of falling increased 1.06 times. This means that for 100 falls in people taking no drugs, there would be 106 falls in people taking one drug, 112 among people taking two drugs, and 118 among people taking three.

Why is this important?

This is a large study, which is representative of the UK care home population.  It concludes that antidepressants and benzodiazepines should be used only when absolutely necessary and stopped as soon as possible. Multiple drug-taking should be kept to a minimum.

The study did not include the duration of drug taking, or other conditions such as arthritis that may have reduced individuals' stability.

But the findings suggest that alternative, non-drug-based therapies based upon the principles of “person centred care” would be safer. Adequate training and staffing levels in care homes will be needed to support non-drug approaches to depression and to symptoms associated with dementia.

The researchers emphasised that their findings should not be interpreted to conclude that antipsychotics are safe, but simply that this study did not find an associated risk of falls.

This study supports current NICE guidance on the association between drug use and falls in older people, and it provides newer data.

What’s next?

Non-drug approaches to depression and the symptoms of dementia are not commonly in place in care homes. The researchers say more work is needed to develop and evaluate new behavioural strategies.

But they believe a move towards alternative approaches will lead to a more multidisciplinary approach to prescribing and a reduction in the medication given to care home residents.

You may be interested to read

The full paper: Izza MAD, and others. Polypharmacy, benzodiazepines, and antidepressants, but not antipsychotics, are associated with increased falls risk in UK care home residents: a prospective multi-centre study. European Geriatric Medicine. 2020. doi: 10.1007/s41999-020-00376-1

Website detailing the wider Falls in Care Homes (FinCH) study, on the clinical and cost effectiveness of fall prevention programmes in care homes

Dhalwani NN, and others. Association between polypharmacy and falls in older adults: a longitudinal study from England. BMJ Open. 2017;7:e016358

Nice Guidance: Falls Assessment and prevention of falls in older people [NG161] (2013), which flags medications such as benzodiazepines and antidepressants as risk factors in care settings, along with multiple medications

A study examining the connection between medications such as benzodiazepines and antidepressants in care settings, along with multiple medications and the associated risks: Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs. Leipzig RM, and others. Journal of the American Geriatric Society. 1999;47:30-39

British Geriatrics Society blog post from FinCH research team member Jane Horne: Falls in Care Homes: “Let’s go and invent tomorrow, instead of worrying about what happened yesterday….” 2020

Funding

This study used data from a project that was funded by the NIHR under its Health Technology Assessment (HTA) programme.

Commentaries

Study author

It is perhaps not new to demonstrate that falls are associated with polypharmacy and psychotropic prescribing, but the fact that these results are current, UK-based, and specific to care homes is helpful to everyone involved in prescribing and in fall prevention in this setting. We have provided factual evidence upon which prescribing and fall prevention actions can be negotiated.

We would advise doctors, falls therapists, care home staff, residents and those acting in their best interests, to recognise that drugs – and in particular antidepressants, benzodiazepines and combinations of medications – carry real risks of increasing falls. This risk should be weighed up against the potential benefit of each drug individually and in combination.

Madeline Izza, Medical Student, School of Medicine, University of Nottingham

Member of the public

This paper will increase awareness of the potential of prescribed drugs to increase the chance of falls. People in care homes and their families, plus those prescribing and administering drugs, need to know about this effect. Care home staff also need to be aware of the increased chance of falls in residents in their care who are taking a cocktail of drugs, especially antidepressants and benzodiazepines. The research is directly relevant to the day to day management of patients in relation to preventing falls.

The main measure will be to ensure clinicians and those administering the drugs are educated on the possible effects of multiple medications. A broader, system-wide approach might be necessary to reduce prescriptions; local government heads of adult social services and directors of public health should be aware of this work.

Gavin Armstrong, Morpeth, Northumberland

Conflicts of Interest

None declared.