Depression, antidepressants and fall risk: therapeutic dilemmas—a clinical review

Abstract

Purpose The aim of this clinical review was to summarize the existing knowledge on fall risk associated with antidepressant use in older adults, describe underlying mechanisms, and assist clinicians in decision-making with regard to (de-) prescribing antidepressants in older persons. Methodology We comprehensively examined the literature based on a literature search in Pubmed and Google Scholar, and identified additional relevant articles from reference lists, with an emphasis on the most commonly prescribed drugs in depression in geriatric patients. We discuss use of antidepressants, potential fall-related side effects, and deprescribing of antidepressants in older persons. Results Untreated depression and antidepressant use both contribute to fall risk. Antidepressants are equally effective, but differ in fall-related side effect profile. They contribute to (or cause) falling through orthostatic hypotension, sedation/impaired attention, hyponatremia, movement disorder and cardiac toxicity. Falling is an important driver of morbidity and mortality and, therefore, requires prevention. If clinical condition allows, withdrawal of antidepressants is recommended in fall-prone elderly persons. An important barrier is reluctance of prescribers to deprescribe antidepressants resulting from fear of withdrawal symptoms or disease relapse/recurrence, and the level of complexity of deprescribing antidepressants in older persons with multiple comorbidities and medications. Practical resources and algorithms are available that guide and assist clinicians in deprescribing antidepressants. Conclusions (De-) prescribing antidepressants in fall-prone older adults is often challenging, but detailed insight in fall-related side effect profile of the different antidepressants and a recently developed expert-based decision aid STOPPFalls assists prescribers in clinical decision-making.

Factors Associated With Severity of Falls In Adult Hospital Patients: A Retrospective Audit

“…Similar to our study, patients with depression were reported to have increased odds for in-hospital fall related major injuries [38]. Depression and the use of antidepressant drug was found to increase falls risk [39,40]. Illicit drug use was reported to be associated with increased odds of injurious falls in patients living with HIV [41].…”

World guidelines for falls prevention and management for older adults: a global initiative

“…If left untreated, symptoms may persist for years. Both untreated depression and antidepressant use contribute to fall risk [ 107 , 128 ]. For details on fall risk and antidepressant use, we refer to the outcomes and recommendations of WG 2 (fall-risk increasing drugs, FRIDs).…”

“…Also, excessive concern about falling contributes to increased fall risk in depressed older adults. It negatively influences gait and balance and thereby increases tendency to fall [ 128 ].…”

Prevalence and Risk Factors of Postoperative Falls Following Foot and Ankle Surgery

“…3,4,21 This is due to the wide variety of adverse effects associated with antidepressants including but not limited to sedation, orthostatic hypotension, and anticholinergic effects. 37,38 Importantly, antidepressant use is reported by almost 13% of people in the United States illuminating that antidepressant use may be one of the most commonly encountered risk factors for postoperative falls by orthopaedic surgeons. 24 Jorgensen et al 13 in 2013 found that pharmacologically treated psychiatric disease was a major risk factor for falls after total hip arthroplasty.…”