Being one of the leading causes of death in the elderly, falls can cause numerous health complications. Prescribing is important to protect the health of the frail and vulnerable, just as much 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 is often common practice for fall prevention, despite an apparent scarcity of robust evidence to support this move. In the community, falls are common, and patient medication should be reviewed regularly.
Despite limited evidence of effectiveness, deprescribing FRIDs is common practice and typically included in both multifactorial and single-intervention strategies. The justification for deprescribing is often based on observational studies that suggest that certain medications are linked to an increased risk of falls, as well as some randomised controlled trials (RCTs) showing 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) searched well-known databases for RCTs of FRID withdrawal compared with usual care, that evaluated rate or incidence of falls, fall-related injuries, fractures or hospitalisations, or adverse effects related to the intervention in adults aged >65 years. Five trials, with a total of 1305 participants, met the eligibility criteria. Deprescribing FRIDs was found not to change the or incidence of falls, nor rate of fall-related injuries over a follow-up period of 6–12 months. None of the included 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. It is therefore extremely important to recognise that are useful for other health purposes may be being needlessly discontinued to prevent falls, while increasing risks of other health concerns, and therefore deprescribing should be practised with caution.
Owing to low-quality evidence, the authors note that it remains unclear whether deprescribing FRIDs as a single intervention leads to any appreciable clinically important benefit or harm. Their current best-effect estimates for falls rate and incidence are centred around no appreciable difference. Although it may be logical to assume as such, Lee et al (2021) state 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. Medication changes may therefore contribute to fall 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 fall prevention strategy. Given the amount of resources being invested into fall prevention initiatives around the world because of the relation of falls to such significantly worsening health outcomes, complex and chronic illness and mortality rates, the researchers have made several recommendations. Lee et al (2021) recommend that clinicians and organisations examine the strength of evidence supporting their current activities, whether they are cost effective and whether resources are being appropriately prioritised to those interventions shown to provide the most value. Lee et al (2021) recommend that this advice should also be applied to what is being required of healthcare organisations in national accreditation standards to optimise use of limited healthcare resources.
It is also important for clinicians and policymakers to consider the current 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 demonstrate the requirement for a comprehensive and individualised approach to falls prevention. Multicomponent interventions are ideal, However, they note interventions may need to be prioritised depending on time, resources and context.
However, while Lee et al (2021) identify insufficient evidence supporting or refuting the deprescribing of FRIDs for fall prevention, they point 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.
Future research
It is unclear whether medication review and management with a broader focus on reducing polypharmacy and potentially inappropriate prescribing in older adults may be beneficial in preventing falls, and this requires further research.
Lee et al′s (2021) review highlights the need for future FRID deprescribing trials that evaluate patient outcomes such as injuries, fractures and hospitalisations. Future research will require a greater attention to optimal research design and reporting in order to enhance the interpretation of results. There would need to be improved reporting of confounding baseline characteristics and intervention fidelity, such as number and types of FRIDs, degree and duration of dose reduction (Lee et al, 2021).
Conclusion
From experience, clinicians will be aware of the high rate of polypharmacy seen in elderly patients in the community. Deprescribing is therefore challenging and extra measures are likely needed to improve successful intervention adherence and follow up. Clearly, there are valid reasons for deprescribing medications when considering risk of adverse events and other factors. However, deprescribing FRIDs as an isolated strategy for the prevention of falls results in little to no difference in the rate and risk of falls or fall-related injuries. The evidence is sparse and generally of low quality, therefore additional well-designed studies should be encouraged to optimise available interventions and establish their relative importance to falls prevention and reduction.