Falls are a common health problem for older people, and psychotropic medications have been identified as an important independent fall risk factor. The objective of this paper was to review the literature relating to the effect of psychotropic medications on falls in older people, with a particular focus on evidence supporting minimization of their use to reduce risk of falls. A literature search identified 18 randomized trials meeting the inclusion criteria for the review of effectiveness of psychotropic medication withdrawal studies, including four with falls outcomes. One of these, which targeted reduced psychotropic medication use in the community, reported a 66% reduction in falls, while the other studies demonstrated some success in reducing psychotropic medication use but with mixed effects on falls. Other randomized trials evaluated various approaches to reducing psychotropic medications generally or specific classes of psychotropic medications (e.g. benzodiazepines), but did not report fall-related outcomes. Overall, these studies reported moderate success in reducing psychotropic medication use, and a number reported no or limited worsening of key outcomes such as sleep quality or behavioural difficulties associated with withdrawal of psychotropic medication use. Reduced prescription of psychotropic medications (e.g. seeking non-pharmacological alternatives to their use in place of prescription in the first place or, for those patients for whom these medications are deemed necessary, regular monitoring and efforts to cease use or wean off use over time) needs to be a strong focus in clinical practice for three reasons. Firstly, psychotropic medications are commonly prescribed for older people, both in the community and especially in the residential care setting, and their effectiveness in a number of clinical groups has been questioned. Secondly, there is strong evidence of an association between substantially increased risk of falls and use of a number of psychotropic medications, including benzodiazepines (particularly, the long-acting agents), antidepressants and antipsychotic drugs. Finally, the largest effect of any randomized trial of falls prevention to date was achieved with a single intervention consisting of weaning psychotropic drug users off their medications.

AimsMisuse of certain drugs is a common precipitant of first-episode psychosis (FEP). Substance misuse is known to exacerbate psychotic symptoms, and it is unclear if substance misuse at the time of initial presentation impacts outcomes of care in FEP. Here, in this quality improvement project (QIP), we aimed to quantify the prevalence of drug misuse within an outpatient early intervention service (EIS) and determine the outcomes (in terms of time-to-discharge and discharge destination) of service users based on their substance misuse history.MethodsIn this QIP, we randomly sampled 100 patients referred to and discharged from an outpatient service for psychosis (Barnet EIS). We excluded patients who were referred to the service but were discharged due to referral rejection, non-attendance at psychiatry review and/or other reasons. Data regarding demographic and clinical information, the nature of substance misuse, and discharge destinations were obtained through a review of electronic health records, including GP letters and hospital notes. The time-to-discharge was defined as the time between referral acceptance and discharge from EIS. As this work is part of a QIP, written consent was not obtained to conduct this project.ResultsOf 100 patients obtained from the discharged caseload, 38 patients were accepted and reviewed in Barnet EIS. 24 patients (63.2%) had no substance misuse history at the time of initial FEP, while 14 patients (36.8%) had some substance misuse history. Of the 14 patients with substance misuse, cannabis was most frequently used. The average age of patients was 27.2 ± 1.4 years old. The age of onset of psychosis was similar between patients with and without substance misuse (two-sample t-test, p = 0.74).In terms of discharge destination, patients with and without substance misuse were discharged back to their GPs at similar proportions (chi-square test, p = 0.81). Finally, the number of days patients spent under the care of Barnet EIS was similar between patients with and without substance misuse (two-sample t-test, p = 0.54).ConclusionIn this QIP, over 30% of patients presenting with FEP reported substance misuse. The most common recreational drug used was cannabis. Discharge destinations and the time spent in EIS were broadly similar between patients with and without substance misuse. The relatively high rates of substance misuse in FEP found in this study have important implications for commissioning additional services – such as urine drug testing or drug liaison services – within EIS teams.