A descriptive observational study on ‘medication-related injurious fall’ amongst elderly patients admitted to a tertiary care teaching hospital

INTRODUCTION

Elderly individuals are an essential part of our society, and the ageing process presents both opportunities and challenges. According to the ‘Elderly in India 2021’ report by the Ministry of Statistics and Programme Implementation, India had approximately 138 million senior citizens aged 60 and above in 2021, representing 10.1% of the total population. Falls are a leading cause of injury amongst the elderly. About 28–35% of the elderly experience falls annually; for those over 70, this rises to 32–42%.^[1] The World Health Organisation (2016) reports that falls constitute the second most prevalent cause of accidental or unintentional mortality on a global scale.^[2] The consequences of falls include physical consequences such as fractures and prolonged immobility, social consequences such as financial costs and loss of independence and psychological consequences such as frustration and fear.^[3,4]

The majority of falls in the elderly have a multifactorial origin. The Institute for Healthcare Improvement broadly categorises the risk factors for recurrent falls into two main groups: Intrinsic and extrinsic. Intrinsic factors include reduced flexibility, unsteady gait, impaired postural control, visual and hearing impairments and coexisting chronic conditions such as cardiovascular disease, diabetes mellitus and osteoporosis. In addition, cognitive and emotional decline, behavioural changes linked to a sedentary lifestyle, contribute significantly. Extrinsic factors are mainly related to environmental hazards, particularly within the home setting, such as slippery floors, uneven surfaces and door thresholds that can precipitate falls.

Notably, medications are considered modifiable risk factors that can increase the likelihood of falls and related injuries. While some risk factors remain beyond an individual’s control, many are preventable or manageable with appropriate interventions. Polypharmacy, often arising from multiple comorbidities, significantly increases the risk of medication-related falls, especially when the patient’s daily regimen includes one or more drugs known to elevate fall risk.^[5] There are many prescribing guidance tools available to assess drug-related fall risk, some of which include fall-risk-increasing drugs (FRIDs) prescribing guidelines, the Beers list, STOPP/START criteria, etc.^[6]

Despite awareness of the potential risks, the prescription of FRIDs remains widespread. Various interventions have been shown to decrease the risk and the rate of falls. Providing education to physicians on fall risks and implementing modifications in clinical practices can help mitigate the occurrence of serious fall-related injuries. A Dutch prospective cohort study involving 139 geriatric outpatients revealed that the complete cessation or, at a minimum, a reduction in the dosage of FRIDs appears to be the most effective intervention for fall prevention. Other strategies to address preventable medication errors include using digital technologies, e.g. computerised systems for drug dosing guidance, along with alerts to detect drug treatment duplication, contraindications and drug interaction errors, which have been proposed to enable better decision-making when prescribing for the elderly.^[7] There is a scarcity of comprehensive studies elucidating the ramifications of FRIDs on the Indian populace. Against this background, this study was planned to assess the profile of regular medications consumed by older (≥65 years) persons at the time of fall-related admission and to identify the probable drug as a risk factor for that fall episode.

MATERIALS AND METHODS

This descriptive observational study was conducted over one calendar year at the trauma centre of a tertiary care hospital in Western India. The study received approval from the Institutional Ethics Committee (Approval No. 354/MC/EC/2023, dated 12 April 2023) and adhered to the ethical principles outlined in the Declaration of Helsinki.

RESULTS

Among the 112 studied older persons with injurious falls, the mean age was 74.9 ± 7.0 years, and 74.1% were females. The study found that 30.3% of elderly patients were using an assistive device for walking, and 31.6% reported a history of previous falls within a year before the present episode. The most common comorbidity found was hypertension (35.7%), followed by coronary artery disease (14.3%). In contrast, 37.5% of persons were devoid of any comorbid condition. Vision and hearing impairment were found in 34.8% and 26.8%, respectively. Cognitive impairment was found amongst 17% of study participants according to the MMSE.

The injurious consequences of the falls were fracture of the femur (76.78%), fracture of the humerus (6.3%), radius (4.5%), ulna (4.5%) and fracture of the metacarpals (0.92%). A few cases of head injury (5.34%), wounds requiring stitches (13.39%) and fracture of the clavicle, ribs and pneumothorax (6.25%) were also reported in the study. At the time of the fall, the mean (±SD) number of routinely prescribed medications was recorded as 1.41 ± 1.74.

Polypharmacy was found in 17.1% of patients, and the mean number of FRIDs was 0.79 ± 1.02 in our study. Amongst the persons with injurious falls, 6.3% received 3 or more FRIDs, 42.9% received 1–2 FRIDs, and 50.89% received no FRIDs [Table 1].

In our study, the most widely used FRIDs in patients of falls were calcium channel blockers (32, 28.6%), pharmacological agents targeting the renin-angiotensin system (17, 15.2%), diuretics (9, 8%) and beta-blockers (9.8%). Apart from antihypertensive medications, the other most common FRIDs received before falls were non-steroidal anti-inflammatory drugs (NSAIDs) (8.9%), benzodiazepines (6, 5.4%), antidepressants (17%) and antidiabetic drugs (8.0%). The FRID amongst antidiabetic drugs (9, 8%) were mainly insulin or sulfonylurea [Figure 1].

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Figure 1:

Regular medications consumed by the study participants.

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Based on the history received from the patients/attendants and hospital records at the time of admission, the probable causes of falls amongst the study participants were orthostatic hypotension (51, 45.5%), impaired cognition (19, 17%), drowsiness (13, 11.6%) and hypoglycaemia (11, 9.8%) [Figure 2].

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Figure 2:

Probable cause of fall amongst the study participants.

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DISCUSSION

With the global population ageing rapidly, falls amongst older adults have become a significant public health issue. Falls represent a major cause of injury and subsequent disabilities, impacting daily functional activities and diminishing quality of life.

In our study, the mean age of the participants was 74.9 ± 7.0 years. The mean age of participants was 87.4 ± 5.7 years in a study done by Milos et al.^[8] and 83.2 ± 7.2 years in a study done by Morin et al.^[9] In our study, the gender distribution included 83 females (74.1%) and 29 males (25.9%); most of the studies also found female predominance. The results indicate that women aged 70 and above are more prone to experiencing falls than men, primarily due to the hormonal changes that occur post-menopause. In our study, the most frequently observed injury was a femur fracture, affecting 86 patients (76.8%), followed by fractures of the elbow and forearm, and head injury. Similarly, Beunza-Sola et al.^[10] reported hip fractures as the most common injury (63%), followed by ankle fractures (7.1%) and pelvic fractures (5.9%). Morin et al.^[9] found that the most prevalent severe injuries were those involving the hip and thigh (28.7%, including 15.5% hip fractures). In our study, the most common comorbidity was hypertension (35.7%), and others were 14.3% coronary artery disease, 9.8% diabetes, 26.8% diminished hearing and 34.8% diminished vision. Interestingly, 37.5% of participants in our study had no existing health conditions. Consistent with our findings, Sharma et al.^[11] found that 56.3% of fallers had hypertension, 18.3% had diabetes, and 12.7% had a history of stroke. Hypertension was observed in 55.3% and diabetes in 56.8% of individuals in a study done by Sharif et al.^[7] Apart from chronic respiratory disorders, anaemia, vertigo or balancing disorders and dementia.

In our study, the assessment of consumption of FRIDs revealed that 42.9% were on 1–2 FRIDs, 6.3% were on >3 FRIDs, and 50.9% were not taking any FRIDs. The mean (±SD) number of FRIDs consumed per patient was 0.79 ± 1.02. Polypharmacy was found in 17.1% of participants, with the mean number of regular medications being 2.61 ± 1.63. These figures are much lower than the study results reported by Beunza-Sola et al.,^[10] which found that over 90% of patients of accidental falls admitted after a bone fracture were taking at least 1 FRID (mean 3.1 ± 1.9 FRIDs/patient with a mean of 7.2 ± 3.6 regular drugs) and De Andrés et al.^[12] where 96% received at least one FRID (3.4 ± 1.8 FRIDs/patient). These high percentages might reflect specific prescribing habits (e.g. some countries prescribe more central nervous system-active or cardiovascular medications), healthcare policies and systems (e.g. drug reimbursement and guidelines vary by locale), and population characteristics (e.g. age distribution, multimorbidity rates or polypharmacy levels differ geographically.

In our study, the most widely used FRIDs in patients of falls were calcium channel blockers (28.6%), drugs acting on the renin-angiotensin system (15.2%), diuretics (8%) and beta-blockers (8%). Beunza-Sola et al.^[10] and two other studies done by Butt et al.^[13] and Solomon et al.^[4] also reported quite similar results while Sharif et al.^[7] found the prevalence of these drug usage much higher (diuretics 65.4% and beta-blockers 61.8%). These categories of medications are commonly prescribed for hypertension and may exacerbate the risk of falls by increasing susceptibility to orthostatic hypotension. The study suggests that adjusting anti-hypertensive medications may reduce syncope and falls. Apart from antihypertensive medications, the other most common FRIDs received before falls in our study participants were NSAIDs (8.9%), benzodiazepines (5.4%), antidepressants (17%) and antidiabetic drugs (8.0%). These findings align with those reported in previous studies on FRIDs. A study by Sharif et al.^[7] found that the prescription of several of the medications classified as FRIDs was hypnotics, sedatives (71.4%), NSAIDs (63%), antidepressants (72.7%) and antipsychotics (66.7%). Similarly, in a study by De Andrés et al.^[12] 80% of patients received a psychotropic drug (mainly benzodiazepines [15.2%] or quetiapine) before the fall. Psychotropic medications can elevate fall risk through side effects such as drowsiness, dizziness and slow reaction time. The use of beta-blockers and insulin may significantly contribute to the risk of falls in the elderly due to postural hypotension and hypoglycaemic effects.

An effective fall injury prevention approach^[15] involving medication includes the following key steps:

CONCLUSION

The world’s elderly population is growing dramatically. Pharmacotherapeutic management in geriatric patients presents a significant challenge due to polypharmacy arising from multimorbidity, particularly when multiple FRIDs are prescribed, which is an independent risk factor for falls. Our study results show that more than 76% of femur fractures occur as a result of falls, with most of these fractures occurring in persons over 70 years of age. Consumption of at least 1 FRID was reported by 42% of the participants. Antihypertensives, analgesics and benzodiazepines were the most commonly prescribed FRID classes, with the probable cause of orthostatic hypotension and drowsiness. Polypharmacy in the form of a regular number of medications >5 was in 17.5% of the study population. As per the analysis of MMSE scoring, patients with cognitive impairment were fewer in comparison to other studies. A significant number of patients were found with diminished hearing and vision. Interventions to reduce falls in the elderly include frequently reviewing all FRIDs for their continued appropriate use. Nevertheless, the reduction of FRIDs constitutes a single element within a broader, multifactorial strategy designed to mitigate fall risk in the elderly.