I heard someone say the other day that “Drugs are clearly not the cause of falls but it is poor balance that is the cause.” I found it interesting since that was said by a physical therapist and sounded a lot like a bias, not unlike a pharmacist I know who is focused on drugs as the cause of falls. However, what I understand to be true about falls is that their cause is usually multi-factorial, involving more than one risk factor, albeit drugs can cause poor balance, altered gait, cognitive impairment, blurred vision, dizziness, leg weakness, and other factors that are validated to contribute to or cause falls in numerous studies. But I must set the record straight that I am the last person to focus just on drugs. In fact, when I am engaging a client while reviewing their medications I also use that discussion as an opportunity to teach them what they can do to reduce their risk for falling. Case in point: A client commented on how the information I provided, that timolol eye drops was a leading risk factors for falls when improperly administered, helped her in regaining balance and stamina, thereby allowing her to stop using her walker. I then cautioned her that her new found confidence could produce a fall since issues could still exist with balance, weakness or gait. I advised that she seek the advice of a physical therapist for a comprehensive assessment.
As a result of hearing this PT’s comment I searched the literature again and looked at falls through a different lens, the one that views the null hypothesis of drugs not causing falls. In an article published in 2003 in Pharmacy & Therapeutics, the authors stated: “Beta- blockers do not contribute to falls”. Perhaps they needed to know about the systemic effects of beta blocker eye drops because Australian data have proven timolol eye drops to be the number one risk factor for falls in patients with glaucoma. (One must also understand that any drug that can cause bradycardia or hypotension can cause a fall.) The authors also stated that “Chronic therapy with blood pressure lowering medications rarely cause falls.” They referred to older studies and meta-analyses from the 1990’s, clearly older evidence that conflicts with more recent data. I found other references that state medications are key contributors to falls, and that is also backed by years of professional experience where changes in antihypertensive medications eliminated dizziness and reduced the incidence of falls. Dr. James Cooper, PharmD, has shown that medications play a key role in causing falls, as reviewed in Medication Interventions for fall prevention in the older adult, Pharmacy Today, 2009 where he referred to his research in reducing the incidence of falls in nursing home residents by 70%. The literature is replete with references showing that alterations in medications reduces the incidence of falls in older adults, and I could fill a few pages with those validated studies.
I am fascinated by the conflicting “evidence” in the literature, and it is now beginning to amuse me. It also shows me that years of reviewing the literature, combined with clinical experience, helps paint a clearer picture that precludes any conclusions from a meta-analysis or retrospective database review that implies cause and effect after “adjusting for confounding factors”. If I followed the advice in some of the literature over the last couple of years I would: Adhere to a complex medication regimen that causes me to be cognitively impaired, dizzy and to fall down the stairs breaking a hip, all because someone said non-adherence causes falls. I would have also stopped taking my calcium, because it is associated with higher risk of death, for which I then might be at greater risk of fracture. I would also have stopped taking a multivitamin with iron and become anemic, thereby further contributing to my risk of falling by causing weakness, and last but not least, I would be typing this post from my nursing home room.
If you don’t know where to look then you won’t know where to find the truth. It’s also wise to work as a team addressing all the identifiable risk factors for falls.