Abstract
Background:
Previous studies have demonstrated increasing mortality due to falls among older adults. The objective of this study was to determine whether there was an increase in fall risk increasing drug prescribing and if this is concurrent with an increase in fall-related mortality in persons 65 years and older in the United States.
Methods:
The study is a serial cross-sectional analysis utilizing data from both the National Vital Statistics System (NVSS) and the medical expenditure panel survey (MEPS) for years 1999–2017. Adults aged 65 years and older were evaluated for death due to falls from the NVSS and for prescription fills of fall risk increasing drugs per the Stopping Elderly Accidents, Deaths, and Injuries-Rx (STEADI-Rx) fall checklist from the MEPS.
Results:
The analysis included 374 972 fall-related mortalities and 7 858 177 122 fills of fall risk increasing drugs. 563 037 964 persons age 65 and older received at least one fall risk increasing drug. Age-adjusted mortality due to falls increased from 29.40 per 100 000 in 1999 to 63.27 per 100 000 in 2017. The percent of persons who received at least one prescription for a fall risk increasing drug increased from 57% in 1999 to 94% in 2017 (p for trend <.0001).
Conclusions and relevance:
Both use of fall risk increasing drugs and mortality due to falls are on the rise. Fall risk increasing drugs may partially explain the increase in mortality due to falls; this cannot be firmly concluded from the current study. Future research examining the potential relationship between fall risk increasing drugs and fall-related mortality utilizing nationally representative person-level data are needed.
Keywords: drug safety, fall risk increasing drugs, fall-related deaths, FRIDs, older adults
1 |. INTRODUCTION
Deaths from falls among persons over 65 are on the rise.1,2 Over 30% of those aged 65 and older report falling each year and age-adjusted death rates from falls have been reported at over 61 per 100 000.1,3 Falls represent a serious hazard to the older population and when not fatal can drastically decrease remaining quality of life.4 This can occur among older adults where the fear of falls leads to activity restriction and is destructive to health.5 Both fatal and nonfatal falls accounted for $50 billion in medical costs in 2015 which represents a sizeable increase from $19.2 billion just 15 years prior.6,7 Fatal falls in older persons exceeds the death rate associated with the opioid epidemic by a factor of four.8,9
Risk factors for falls are numerous. As with most morbidities, age is a risk factor. The risk of falls increases around age 65 and continues to increase each subsequent year.10 Other important risk factors include: a history of falls, fear of falling, unsteady gait, vision impairment, and depression.5,11 Apart from various environmental factors, polypharmacy has been implicated as a risk factor for falls in the elderly.12 More specifically, certain medications are considered fall risk increasing drugs (FRIDs).13–15 This is important because, in some cases, medications are a potentially modifiable risk factor for falls.15 Multiple studies have assessed the association between FRIDs and outcomes such as injurious falls and hip fractures.16–18 Fewer studies have been conducted to assess the impact of FRID prescribing on fall-related mortality in among older adults.19
The objectives of this study are 2-fold: one, to describe the trend in mortality due to falls over the study period among persons aged 65 years and older and two, to describe the trend in fills for prescription FRIDs in persons aged 65 years and older. We hypothesize that mortality due to falls are increasing concurrent with an increase in fills for FRIDs.
2 |. METHODS
2.1 |. Data
The study utilized the National Vital Statistics System’s (NVSS) database of all death records spanning deaths in the United States from January 1, 1999 through December 31, 2017. Deaths were ascertained through CDC WONDER (Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research), an online tool for accessing NVSS data.20
The study also utilized the medical expenditure panel survey (MEPS), a survey administered by the agency for healthcare research and quality (AHRQ). The MEPS population consists of a subset of households who participated in the previous year’s National Health Interview Survey. Respondents are part of the non-institutionalized population and provide information over 2.5 years and five survey rounds (spaced 5–6 months apart); this information covers 2 years’ worth of a respondent’s information. The MEPS oversamples from Hispanics, Blacks, Asians, and low-income individuals to increase the precision of generated estimates. The MEPS also utilizes sample weights so as to ensure that the final estimates derived are nationally representative. This study utilized the MEPS household component, namely one of its constitutive files, the prescribed medicines file, which contains medicine names and National Drug Codes (NDC). Both sources offer the researcher deidentified and publicly available data and as such both are exempt from institutional review board review.
2.2 |. Outcomes
Fall-related mortality was ascertained using CDC WONDER specifying International Classification of Disease Tenth Revision (ICD-10) codes W00-W19.20 Fall-related mortalities were specified for age, sex, and race.
FRIDs were defined according to the CDC’s Stopping Elderly Accidents, Deaths, and Injuries-Rx (STEADI-Rx) fall checklist.21 The STEADI tool kit was developed by the CDC as a resource for healthcare providers to use to address fall prevention. STEADI-Rx, a more specific subset of the STEADI toolkit, was formed to foster collaboration between medical providers and pharmacists as a way of increasing patient screening and decreasing morbidity and mortality among seniors due to falls. Medications identified on the “Community Pharmacy Fall Risk Checklist” include anticonvulsants, antidepressants (second-generation antidepressants), antihypertensives, antipsychotics, benzodiazepines, opioids, sedative hypnotics, tricyclic (first-generation) antidepressants, and other nonprescription medications. In this study, we identified all first-generation antihistamines to assess this final category. Using the STEADI-Rx list, fills were categorized as a FRID or not based on both drug name and NDC with adjustment made for NDCs that changed based on year.
2.3 |. Statistical analysis
Direct age standardization was completed using the 2000 US Census as the standard population. Mortality was indicated as both absolute number of deaths and rate as deaths per 100 000 persons aged 65 years and older. In order to account for correlations in mortality from year to year a linear autoregressive model was used to test for trend over time and a p < .05 was considered significant.
Count of overall fills and fills of FRIDs for persons 65 years and older for each year of the study period were recorded. Number of persons receiving at least one FRID was collected for each year. In order to account for correlations in prescribing patterns over time a linear autoregressive model was used to test for trend in each category of FRID over time and a p < .05 was considered significant. Given the large percentage of prescriptions made up by antihypertensives during the study period a sensitivity analysis was conducted without antihypertensives included to determine if trends were similar without their influence. As all FRID information was derived from MEPS, all analysis conducted on FRIDs was done with the appropriate survey weights provided by AHRQ. All analysis was conducted utilizing SAS 9.4 (SAS Institute, Cary, NC).
2.4 |. Results
Over the study period 374 972 fall-related mortalities occurred (Table 1). Falls increased across all demographics (sex, race, age category) significantly (p for trend <.0001). The mortality rate per 100 000 among Black women increased from 12.36 in 1999 to 19.35 in 2017 representing more than a 56% increase. Among all races, aged 75–84 the mortality rate increased from 31.54 per 100 000 to 62.68 per 100 000, a 98.7% increase. The largest percent increase in mortality rate was seen in White women who were 85 years and older from 102.62 to 272.65, an increase of over 160%.
TABLE 1.
Mortality rates from falls by age, sex and race among Persons 65 years and older in the United States, 1999–2017
| 1999 | 2005 | 2011 | 2017 | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Deaths/population | Mortality rate (95% CI) | Deaths/population | Mortality rate (95% CI) | Deaths/population | Mortality rate (95% CI) | Deaths/population | Mortality rate (95% CI) | |||
| ≥65a | Overall | 10 097/34 797 841 | 29.40 (28.83–29.97) | 15 802/36 649 798 | 42.29 (41.63–42.95) | 22 901/41 394 141 | 53.66 (52.96–54.36) | 31190/50 858 679 | 63.27 (62.56–63.98) | |
| Men | 4 678/14 300 511 | 38.33 (37.21–39.45) | 7 239/15 447 939 | 52.47 (51.25–53.69) | 10 471/17 943 371 | 64.54 (63.30–65.78) | 14 650/22 564 684 | 74.89 (73.67–76.11) | ||
| White | 4 341/12 797 631 | 39.59 (38.39–40.79) | 6 756/13 641 011 | 54.66 (53.34–55.97) | 9 757/15 668 815 | 67.73 (66.38–69.08) | 13 630/19 375 375 | 80.02 (78.67–81.38) | ||
| Black | 229/1 090 557 | 23.49 (20.35–26.63) | 288/1 219 988 | 28.11 (24.75–31.47) | 389/1 453 841 | 31.42 (28.21–34.64) | 535/1 954 319 | 33.11 (30.21–36.02) | ||
| Other | 108/412 323 | 35.15 (28.27–42.02) | 195/586 940 | 43.78 (37.46–50.10) | 325/820 715 | 49.07 (25.14–31.85) | 485/1 234 990 | 47.07 (42.83–51.32) | ||
| Women | 5419/20 497 330 | 24.34 (23.69–24.99) | 8563/21 201 859 | 35.94 (35.17–38.80) | 12430/2 345 0770 | 46.34 (45.51–47.17) | 16 540/2 829 3995 | 54.92 (54.07–55.77) | ||
| White | 5126/18 167 957 | 25.55 (24.85–26.25) | 8 069/18 495 164 | 37.96 (37.13–38.80) | 11 806/20 158 259 | 50.05 (49.13–50.97) | 15 544/23 812 076 | 60.08 (59.12–61.04) | ||
| Black | 219/1 773 388 | 12.36 (10.72–14.00) | 322/1 930 726 | 16.91(15.06–18.76) | 346/2 226 936 | 15.60 (13.95–17.25) | 535/2 881 002 | 19.35 (17.69–21.00) | ||
| Other | 74/555 985 | 16.09 (16.09–20.29) | 172/775 969 | 24.89 (21.15–228.64) | 278/1 065 575 | 28.49 (25.14–31.85) | 461/1 600 917 | 30.75 (27.92–33.59) | ||
| 65–74b | Overall | 1663/18 418 909 | 9.03 (8.59–9.46) | 2319/18 881 697 | 12.28 (11.78–12.78) | 3149/22 481 738 | 14.01 (13.52–14.50) | 4752/29 683 446 | 16.01 (15.55–16.46) | |
| Men | 1027/8 293 485 | 12.83 (11.63–13.14) | 1384/8 683 128 | 15.94 (15.10–16.78) | 1926/10 476 313 | 18.38 (17.56–19.21) | 2937/13 877 140 | 21.16 (20.40–21.93) | ||
| White | 904/7 351 198 | 12.30 (11.50–13.10) | 1253/7 546 906 | 16.60 (15.68–17.52) | 1714/9 033 095 | 18.97 (18.08–19.87) | 2638/11 813 232 | 22.33 (21.48–23.18) | ||
| Black | 100/679 960 | 14.71 (11.82–17.59) | 92/465 660 | 12.02 (9.69–14.74) | 141/924 403 | 15.25 (12.74–17.77) | 195/1 289 007 | 15.13 (13.00–17.25) | ||
| Other | 23/262 327 | 8.77 (5.56–13.16) | 39/370 562 | 10.52 (7.48–14.39) | 71/518 815 | 13.69 (10.69–17.26) | 104/774 901 | 13.42 (10.84–16.00) | ||
| Women | 636/10 125 424 | 6.28 (5.79–6.77) | 935/10 198 569 | 9.17 (8.58–9.76) | 1223/12 005 425 | 10.19 (9.62–10.76) | 1815/15 806 306 | 11.48 (10.95–12.01 | ||
| White | 565/8 817 573 | 6.41 (5.88–6.94) | 835/8 699 401 | 9.60(8.95–10.25) | 1124/10 148 742 | 11.08 (10.43–11.72) | 1631/13 139 486 | 12.41 (11.81–13.02) | ||
| Black | 51/964 120 | 5.29 (3.94–6.96) | 64/1 047 563 | 6.11 (4.70–7.80) | 64/1 237 777 | 5.17 (3.98–6.60) | 111/1 709 818 | 6.49 (5.28–7.70) | ||
| Other | 20/343 731 | 5.82 (3.55–8.99) | 36/451 605 | 7.97 (5.58–11.04) | 35/618 906 | 5.66 (3.94–7.86) | 73/9 57 002 | 7.63 (5.98–9.59) | ||
| 75–84b | Overall | 3856/12 224 914 | 31.54 (30.55–32.54) | 5957/13 074 802 | 45.56 (44.40–46.72) | 7.387/13 175 230 | 56.07 (54.79–57.35) | 9218/14 706 551 | 62.68 (61.40–63.06) | |
| Men | 1950/4 813 716 | 40.51 (38.71–42.31) | 3051/5 320 967 | 57.34 (55.30–59.37) | 3835/5 573 033 | 68.81 (66.64–70.99) | 4926/6 407 875 | 76.87 (74.73–79.02) | ||
| White | 1828/4 367 114 | 41.86 (39.94–43.78) | 2848/4 782 262 | 59.55 (57.37–61.74) | 3568/4 925 953 | 72.43 (70.06–74.81) | 4551/5 549 805 | 82.00 (79.62–84.39) | ||
| Black | 79/325 255 | 24.29 (19.23–30.27) | 128/365 737 | 35.00 (28.93–41.06) | 144/414 645 | 34.73 (29.06–40.40) | 185/511 629 | 36.16 (30.95–41.37) | ||
| Other | 43/121 347 | 35.44 (25.64–47.73) | 75/172 968 | 43.36 (34.11–54.35) | 123/232 435 | 52.92 (43.57–62.27) | 190/346 441 | 54.84 (47.05–62.64) | ||
| Women | 1906/7 411 198 | 25.72 (24.56–26.87) | 2906/7 753 835 | 37.48 (36.12–38.84) | 3552/7 602 197 | 46.72 (45.19–48.26) | 4292/8 298 676 | 51.72 (50.17–53.27) | ||
| White | 1804/6 663 647 | 27.07 (25.82–28.32) | 2708/6 862 193 | 39.46 (37.98–40.95) | 3323/6 579 562 | 50.50 (48.79–52.22) | 3995/7 034 954 | 56.79 (55.03–58.55) | ||
| Black | 76/580981 | 13.08 (10.31–16.37) | 129/642773 | 20.07 (16.61–23.53) | 116/696468 | 16.66 (13.62–19.69) | 151/814516 | 18.54 (15.58–21.50) | ||
| Other | 26/166 570 | 15.61 (10.20–22.87) | 69/248 869 | 27.73 (21.57–35.09) | 113/326 167 | 34.64 (28.26–41.03) | 146/449 206 | 32.50 (27.23–37.77) | ||
| ≥85b | Overall | 4578/4 154 018 | 110.21 (107.01–113.40) | 7526/4 693 299 | 160.36 (156.73–163.98) | 12 365/5 737 173 | 215.52 (211.73–219.32) | 17 220/6 468 682 | 266.21 (262.23–270.18) | |
| Men | 1701/1193 310 | 142.54 (135.77–149.32) | 2804/1 443 844 | 194.20 (187.02–201.39) | 4710/1 894 025 | 248.68 (241.57–255.78) | 6787/2 279 669 | 297.72 (290.64–304.80) | ||
| White | 1609/1 079 319 | 149.08 (141.79–156.36) | 2655/1 311 843 | 202.39 (194.69–210.09) | 4475/1 709 767 | 261.73 (254.06–269.40) | 6441/2 012 338 | 320.08 (312.26–327.89) | ||
| Black | 50/85 342 | 58.59 (43.49–77.24) | 68/88 591 | 76.76 (59.61–97.31) | 104/114 793 | 90.60 (73.19–108.01) | 155/153 683 | 100.86 (84.98–116.73) | ||
| Other | 42/28 649 | 146.60 (105.66–198.16) | 81/43 410 | 186.59 (148.18–231.92) | 131/69 465 | 188.58 (156.29–220.88) | 191/113 648 | 168.06 (144.23–191.90) | ||
| Women | 2877/2 960 708 | 97.17 (93.62–100.72) | 4722/3 249 455 | 145.32 (141.17–149.46) | 7655/3 843 148 | 199.19 (194.72–203.65) | 10 433/418 9013 | 249.06 (224.28–253.84) | ||
| White | 2757/2 686 737 | 102.62 (98.78–106.45) | 4526/2 933 570 | 154.28 (149.79–158.78) | 7.359/3 429 955 | 214.55 (209.65–219.45) | 9918/3 637 636 | 272.65 (267.28–278.02) | ||
| Black | 92/228 287 | 40.30 (32.49–49.42) | 129/240 390 | 53.66 (44.40–62.92) | 166/292 691 | 56.72 (48.09–65.34) | 273/356 668 | 76.54 (67.46–85.62) | ||
| Other | 28/45 684 | 61.29 (40.73–88.58) | 67/75 495 | 88.75 (68.78–112.71) | 130/120 502 | 107.88 (89.34–126.43) | 242/194 709 | 124.29 (108.63–139.95) |
Note: Other combines: Native American or Alaska Native and Asian or Pacific Islander.
Age-adjusted mortality rates as deaths per 100 000 persons.
Crude mortality rates.
Age-adjusted mortality due to falls increased from 29.40 per 100 000 (95% CI, 28.83–29.97) in 1999 to 63.27 per 100 000 (95% CI, 62.56, 63.98) in 2017 (Figure 1).
FIGURE 1.
Trend in falls mortality* and Persons with fills of fall-risk increasing drugs. Asterisk indicates age-adjusted falls-related mortality
From 1999–2017 over 7.8 billion (95% CI, 7.5 billion; 8.2 billion) prescriptions for FRIDs were filled (this number includes refills). The number of persons who received at least one prescription for a FRID increased from 57% in 1999 to 94% in 2017 (p for trend <.0001) (Figure 1). A majority were filled by those who were 65–74 years old (52.8%), female (57.7%) and white (86.3%) (Table 2). A significant overall increasing trend in the percent of persons with at least one fill from a FRID was seen among males and females, both White and Black (p < .0001) (Figure 2). In particular, the percentage of Black women receiving FRIDs is greater than either their White counter-parts or men of any race (Figure 2).
TABLE 2.
Characteristics of persons receiving at least one fill of a fall risk increasing drug
| Characteristic | Received no FRID n = 180 801 509 | Received ≥1 FRID n = 563 037 964 | p |
|---|---|---|---|
| Age (years) | <.0001 | ||
| 65–74 | 110 830 639 (61.3%) | 297 438 672 (52.8%) | |
| 75–84 | 52 557 930 (29.1%) | 198 718 862 (35.3%) | |
| 85+ | 17 412 940 (9.6%) | 66 880 431 (11.9%) | |
| Sex | <.0001 | ||
| Male | 83 695 434 (46.3%) | 238 174 770 (42.3%) | |
| Female | 97 106 075 (53.7%) | 324 863 194 (57.7%) | |
| Race/ethnicity | <.0001 | ||
| White | 155 370 810 (86.0%) | 485 740 487 (86.3%) | |
| Black | 13 921 263 (7.7%) | 50 440 704 (9.0%) | |
| Asian/Pacific Islander | 9 347 577 (5.2%) | 18 205 228 (3.2%) | |
| Native American/Alaska Native | 711 478 (0.4%) | 2 836 405 (0.5%) | |
| Other | 1 450 381 (0.8%) | 5 815 140 (1.0%) |
Note: prepresents the result of a Chi-square test for difference.
Abbreviation: FRID, fall risk increasing drug.
FIGURE 2.
Trend in percentage of Persons prescribed FRIDs by race and sex
A sensitivity analysis excluding antihypertensive medications also showed an increase in the percentage of persons receiving FRIDs from 63 536 837 in 1999 to 163 010 844 in 2017 (p for trend <.0001) (Figure 3).
FIGURE 3.
Percent of persons receiving at least one FRID by drug class, 1999–2017. The data present the percent of the study population receiving one or more FRID prescriptions from 1999 to 2017 organized by drug class. Antihypertensives were excluded from this figure for readability
The use of antidepressants has increased dramatically in this population from 12 million fills to over 52 million in 2017 (p for trend <.0001); this translates to an increase from 7% to 16% of the 65 and older population receiving an antidepressant (Figure 3). The increase in antidepressants is concurrent with a slight decrease in tricyclic antidepressants (TCAs) from 4% in 1999 to 2% in 2017. The percentage of the population receiving an opioid reached a high in 2015 of 21%, but began declining to a 2017 level of 16%. Over the entire study period, 75.7% of (95% CI, 72.8, 78.5) persons age 65 and older received at least one FRID with the majority of FRIDs coming from the antihypertensive class (Table 3).
TABLE 3.
Percent of FRID fills by class over the study period (1999–2017)
| FRID Class | FRID Fills (n = 7 858 177 122) |
|---|---|
| Antihypertensives | 71.2 |
| Antidepressants | 8.1 |
| Opioids | 7.4 |
| Benzodiazepines | 4.4 |
| Anticonvulsants | 3.8 |
| Antihistamines | 1.3 |
| Tricyclic antidepressants | 1.3 |
| Sedative hypnotics | 1.2 |
| Antipsychotics | 0.9 |
| Antispasmodics | 0.5 |
Note: Data are presented as % of total FRID prescriptions filled by the study population from 1999 to 2017 organized by FRID class.
Prescribing of multiple FRID classes has increased. TCAs and antihistamines were prescribed to 1 799 016 persons over the study period, while TCAs and second-generation antidepressants were prescribed to 4 388 639 persons (Table 4). Benzodiazepines and sedative hypnotics were prescribed to 4 723 484 persons while benzodiazepines and opiates were prescribed to 23 660 904 persons. Percentage of persons receiving both opiates and benzodiazepines reached an apex of 3.7% (or, 1 811 142 persons) in 2015 falling to 2.8% (1 457 753 persons) in 2017.
TABLE 4.
Percentage of persons (N = 743 839 473) receiving select combinations of multiple FRID classes over the study period (1999–2017)
| Anticonvulsants | Antidepressants | Antihistamines | Anti-HTN | Antipsychotics | Antispasmodics | BZDs | Opioids | Sed. Hyp. | TCAs | |
|---|---|---|---|---|---|---|---|---|---|---|
| Anticonvulsants | X | 2% | 1% | 6% | 0% | 0% | 1% | 3% | 0% | 0% |
| Antidepressants | 2% | X | 1% | 10% | 1% | 0% | 3% | 4% | 1% | 1% |
| Antihistamines | 1% | 1% | X | 3% | 0% | 0% | 1% | 2% | 0% | 0% |
| Anti-HTN | 6% | 10% | 3% | X | 1% | 1% | 7% | 14% | 2% | 2% |
| Antipsychotics | 0% | 1% | 0% | 1% | X | 0% | 1% | 1% | 0% | 0% |
| Antispasmodics | 0% | 0% | 0% | 1% | 0% | X | 0% | 1% | 0% | 0% |
| BZDs | 1% | 3% | 1% | 7% | 1% | 0% | X | 3% | 1% | 1% |
| Opioids | 3% | 4% | 2% | 14% | 1% | 1% | 3% | X | 1% | 1% |
| Sed. Hyp. | 0% | 1% | 0% | 2% | 0% | 0% | 1% | 1% | X | 0% |
| TCAs | 0% | 1% | 0% | 2% | 0% | 0% | 1% | 1% | 0% | X |
Abbreviations: Anti-HTN, antihypertensives; BZDs, benzodiazepines; Sed. Hyp., sedative hypnotics; TCAs, tricyclic antidepressants.
3 |. DISCUSSION
The results of this ecological study suggest that the prescribing of FRIDs and fall-related mortality have concurrently been increasing between 1999 and 2017. Previous studies have identified an association between the use of FRIDs and adverse clinical outcomes such as injurious falls and hip fractures.16–18 The contribution of FRIDs to fall-related mortality is less well understood. Kragh Ekstam et al. found that use of four or more FRIDs, use of five or more drugs, and use of psychotropic or cardiovascular drugs were associated with first-year mortality among hip fracture patients in a Swedish population-based cohort study.19 Use of FRIDs may partially explain the increase in mortality due to falls found in the present study. A recent study by Hartholt et al. demonstrated a positive relationship between increasing age and falls-related mortality in the U.S. among older adults (over 75 years old) between 2000 and 2016 utilizing the NVSS.2 These authors found that the increase in mortality was the most profound among the oldest age groups. Our results suggest that the prevalence of FRID prescribing is greater in those over the age of 85 years. Interventions targeting the deprescribing of FRIDs may be best targeted toward older, frailer patients.
FRID use increased throughout the study period throughout all subgroups in our analysis stratifying by race and gender. Notably, use of FRIDs was considerably higher among females. This is relevant as female gender has been identified as an independent risk factor for falls and fractures.22,23 This highlights the importance of additional patient risk factors for falls when considering making medication interventions.
The FRID category with the most dramatic increase in prescribing over the study period was antidepressants. This category includes second-generation antidepressants such as selective-serotonin reuptake inhibitors (SSRI), serotonin-norepinephrine reuptake inhibitors (SNRI), and various agents with novel mechanisms (ex. mirtazapine, trazodone, nefazodone, bupropion).24 The trend toward prescribing more from the antidepressant category occurred simultaneously with a negative trend in prescribing TCAs, first-generation antidepressants. The increase in use of these agents over the study period is likely related to these agents being recommended as first line agents for a number of conditions such as major depressive disorder and generalized anxiety disorder as well as use for other indications such as neuropathic pain.8,25 Our results do indicate an increase in antidepressant prescribing following recommendations to utilize antidepressants in lieu of opioids for pain in 2009; however, the decrease in opioid prescribing did not start until 2014.8 However, data suggest that these agents increase the risk of falls and hip fractures to an extent similar to results highlight the need for evidence-based screening and deprescribing interventions for FRIDs among older adults and supports the goals of National Council on Aging “2015 Falls Free® National Action Plan.”27 The American Geriatrics Society and British Geriatrics Society published guidelines for fall prevention in 2011 emphasized the benefit of medication reviews and medication reduction as important interventions.28 The CDC STEADI toolkit was developed in 2013 and made available as a resource for clinicians to identify patients at risk and intervene to prevent falls.10 Despite the availability of these resources, our results suggest that prescribing of FRIDs has continued to increase. A recent randomized-controlled trial sought to implement STEADI-Rx in the community pharmacy setting to assess the impact on FRID discontinuation and risk of falling.29 In this intervention, patients were screened with the STEADI algorithm and those with a positive screen received a pharmacist-conducted medication review with recommendations sent to the patient’s provider. This study did not show a significant change in fall risk or use of FRIDs relative to the control group. These results highlight the complex nature of prescribing in older adults in which clinicians may recognize the risks but consider the benefits of higher value.
This study has a number of limitations. FRIDs were identified based on an available toolkit endorsed by the CDC; however, additional drugs or classes of drugs may also contribute to fall risk. The study design prevents the possibility of testing for a direct association between exposure to FRIDs and fall-related mortality as the data were extracted from separate databases. Although an adjustment for increasing prevalence of comorbidities would be helpful in the interpretation of this data, such an analysis was beyond the scope of the present study. Finally, although NVSS provides a report of all recorded deaths in the country, MEPS pulls from the non-institutionalized population and as such does not capture the trends in prescribing of, for example, the nursing home population. Future research examining the potential relationship between FRIDs and fall-related mortality utilizing nationally representative person-level data including adjustment for secular trends are warranted to investigate the signal uncovered by this study.
4 |. CONCLUSIONS
The study shows that both the use of FRIDs and mortality due to falls is increasing. Although these two trends may be related without further work at an individual level that cannot be definitively concluded. However, given the strength of the signal, future research examining the potential relationship between FRIDs and fall-related mortality utilizing nationally representative person-level data are being planned.
ACKNOWLEDGEMENT
Dr. Shaver is supported in part by an Interdisciplinary Training in Cancer Epidemiology Grant T32CA113951. The work was previously presented as a poster at the American College of Clinical Pharmacy annual meeting (May 2020, virtual) and as a poster at American Pharmacists Association annual meeting (May 2020, virtual).
Funding information
National Institutes of Health; Interdisciplinary Training in Cancer Epidemiology, Grant/Award Number: T32CA113951
Footnotes
CONFLICT OF INTEREST
The authors have no conflicts of interest to declare.
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