Antidepressants and Falls in the Elderly

Abstract

Antidepressants have long been recognized as a contributory factor to falls and many studies show an association between antidepressants and falls. There are extensive data for tricyclic antidepressants (TCAs) and related drugs, and for selective serotonin reuptake inhibitors (SSRIs), but few data for other classes of antidepressants. Sedation, insomnia and impaired sleep, nocturia, impaired postural reflexes and increased reaction times, orthostatic hypotension, cardiac rhythm and conduction disorders, and movement disorders have all been postulated as contributing factors to falls in patients taking antidepressants. Sleep disturbance is a cardinal feature of depression, and all antidepressants have effects on sleep. TCAs and related drugs cause marked sedation with daytime drowsiness. SSRIs and related drugs have an alerting effect, impairing sleep duration and quality and causing insomnia, which may result in nocturia and daytime drowsiness. Daytime drowsiness is a significant risk factor for falls, both in untreated depression and in depression treated with antidepressants. Clinically significant orthostatic hypotension is common with TCAs and related drugs, the older monoamine oxidase inhibitors and serotonin-norepinephrine reuptake inhibitors (SNRIs). It occurs less commonly with SSRIs, and rarely with moclobemide and bupropion, and is not reported as a significant adverse effect of hypericum (St John's wort). Cardiac rhythm and conduction disturbances are well recognized with TCAs, tetracyclics and SNRIs, but have also been reported with SSRIs. The contribution of antidepressant-induced conduction and rhythm disturbances to falls cannot be assessed with current data. There are insufficient data to exonerate any individual antidepressant or class of antidepressants as a potential cause of falls. The magnitude of the increased risk of falling with an antidepressant is about the same as the excess risk found in patients with untreated depression.

Antidepressant use and 10-year incident fracture risk: the population-based Canadian Multicentre Osteoporosis Study (CaMoS)

“…These drugs have an alerting effect, impairing sleep duration and quality and causing insomnia, which may result in daytime drowsiness [28]. This can contribute to increase the risk of fall, a well-known contributor to fracture risk.…”

The Safety, Tolerability and Risks Associated with the Use of Newer Generation Antidepressant Drugs: A Critical Review of the Literature

“…Postural hypotension associated with the use of SSRIs is most commonly observed in elderly populations [83]. Paroxetine seems to be the SSRI most frequently associated with orthostatic hypotension at least partly due to its anticholinergic effects [85]. This increased anticholinergic effect may help explain the increased risk of orthostatic hypotension especially in the elderly [86].…”

A study of the safety and harms of antidepressant drugs for older people: a cohort study using a large primary care database

“…There is a large literature on the risk of falls in relation to antidepressant drugs among older people, 148,149 with some studies suggesting that the risk for TCAs is similar to that for SSRIs, 150,151 while others suggest that SSRIs have the highest risk. 152 Few studies have examined effects of individual drugs.…”

“…A review of 78 studies 148 found that although there are extensive data for TCAs and SSRIs, there are few data for other antidepressant drugs. The effects of TCAs and SSRIs on the risk of falls were found to be generally similar across studies.…”