Preventing Falls in the Elderly: Interventions, Risks, Benzodiazepines and Personalized MedicineRuslan Dorfman
Falls are the most common cause of injury and injury-related hospitalizations in the elderly. According to the Canadian Community Health Survey, between 20-30% of seniors fall each year. Falls in seniors are estimated to directly cost over $2 billion per year in Canada alone.
Falls account for 95% of all hip fractures, and the elderly are much more likely to suffer serious injury, such traumatic brain injury, and death from a ground level fall.
Given an aging population, researchers strive to determine the most effective ways to prevent seniors from falling.
A new large-scale study published in the Journal of the American Medical Association compared different interventions to prevent falls in the elderly. Researchers looked at health data from a total of 159 910 elderly participants, with an average age of 78 years. Different combinations of interventions were compared instead of only comparing single interventions, (i.e. exercise vs environmental assessment), as has often been done in other studies.
The study concluded that the following single and combined interventions were associated with lower risk of falling in the elderly, compared with standard care practices:
- Exercise (such as walking and balance training)
- Exercise combined with vision testing and treatment
- Exercise combined with vision testing and treatment and environmental assessment and modification (i.e. installing grab bars, removing trip hazards)
- Clinic-level quality-improvement strategies (i.e. staff education, assigned case management) combined with multifactorial assessment and treatment (i.e. comprehensive geriatric assessment) and vitamin D and calcium supplementation
These findings highlight the importance of exercise, as well as the importance of multicomponent interventions specific to individuals in a case-by-case basis.
Why do seniors fall?
The risk of falling depends on the individual. Factors such as decline in physical fitness, impaired vision, diseases like Parkinson’s, Alzheimer’s and arthritis, surgical procedures such as hip replacements, poor nutrition, and medications all contribute to the risk of falling.
What about medications?
According to the Merck Manual, over 40% of seniors take at least five drugs per week. Medications can increase the risk of falling due to side-effects such as drowsiness, dizziness and low blood pressure. These side-effects can be caused by psychotropic drugs (medications that alter mood), sedatives (medications that induce calm), hypnotics (medications that induce sleep), antidepressants, opioids and some cardiovascular drugs. Benzodiazepines are a class of drug that acts as a hypnotic, sedative, and anticonvulsant, and has been strongly associated with increased risk of falling in seniors.
Benzodiazepines and falling in the elderly
Benzodiazepines are one of the most prescribed drugs for the elderly, and one of the most misused. Benzodiazepines include drugs like Valium, Ativan and Xanax.
A 2016 study published in the journal of the American Medical Directors Association found that benzodiazepine use was associated with a 43% increased risk of hip fractures in Alzheimer’s patients.
Another study that looked at data over a period of 10 years found that benzodiazepine usage was responsible for almost 20 000 falls every year in seniors over the age of 80 in France, causing nearly 1800 deaths.
Often prescribed for panic attacks, anxiety and insomnia, benzodiazepines are meant to be taken short-term – less than a few weeks. Yet they are often taken long-term which can lead to dependency and neurological damage. Almost 80% of all seniors prescribed benzodiazepines continue to take them for over 2 years. Unfortunately, stopping benzodiazepines after long-term use is not only difficult, but stopping suddenly can be extremely dangerous.
How do Benzodiazepines work?
Benzodiazepines impact the receptors of gamma-aminobutyric acid (GABA-a), a hormone in the brain. GABA makes you feel relaxed and peaks when you are asleep. Benzodiazepines do not create more GABA, but instead make existing GABA linger longer in the brain. This allows for more interaction between GABA and the GABA receptors, which increases the feeling of relaxation. GABA offsets glutamate, the excitatory chemical in the brain. The problem with long-term benzodiazepine use is that eventually GABA receptors begin to atrophy, and more GABA is needed to achieve the same feeling of relaxation.
How individuals respond to benzodiazepines can vary greatly. Depending on your inherited metabolism, some people process these medications very differently. People who metabolize poorly are more at risk of adverse side-effects, such as drowsiness and dizziness.
Different benzodiazepine medications are metabolized by various liver enzymes including CYP2C19 and CYP3A4. Benzodiazepine effectiveness and risk of side effects is related to inherited variations in these genes.
Pillcheck can help predict side-effects that increase the risk of falling
Personalizing fall prevention is critical. Determining if your blood pressure medication is too strong or whether you are unable to metabolize benzodiazepines effectively can greatly help prevent the side-effects that increase risk of falling. Pillcheck can determine which medications are right for elderly patients and can contribute to multicomponent interventions aimed at preventing falls.
Canadian statistics on falls in seniors:
JAMA study investigating interventions to prevent falling in seniors:
Comparisons of Interventions for Preventing Falls in Older Adults: A Systematic Review and Meta-analysis. Tricco AC, et al. Journal of the American Medical Association. 2017: Volume 318(17), p1687-1699.
French study looking at Benzodiazepines and falls in elderly:
Benzodiazepines and hip fractures in Alzheimer patients: