This is the first study to our knowledge to investigate the associations between falls, recurrent falls, and a fall risk-increasing drug, polypharmacy, and inappropriate medication use in community-dwelling older adults in Turkey. There is a limited number of studies in the literature evaluating the relationship between recurrent falls and polypharmacy. The relationship between certain drug groups and falls and recurrent falls could not be clearly shown in this study, as in other studies. In this study, 55.6% of older adults had polypharmacy, and 29.1% of the study participants had used at least one PIMs. Thirty-two percent of older adults had fallen at least once in the past year, and 48.5% of falling participants reported recurrent falls. In our research, having low HGS increases the risk of falling, and older age and ACE-I usage increases the risk of recurrent falling. The fall rate in this study (32%) is lower than in several other studies of older adults, which reported fall rates of 13.1 to 41.8% and recurrent fall rates of 13.1 to 86.9% (4, 6, 24). These studies were carried out with either unhealthy (e.g., people with chronic stroke) or different populations (e.g., home health patients). However, no relation was found between polypharmacy and falling or recurrent falling.”
In the literature, the prevalence of polypharmacy ranges from 25–90% (1,3,5,24 ). In our study, the polypharmacy prevalence was 55.6%. Different types of drugs have been reported as the most used in previous studies (5, 24). In this study, the most widely used drugs were diuretics, ARB, biguanides, PPI, and ASA. This is due to the differences in the drugs preferred across populations and the lack of standardization in drug selection worldwide.
Studies have shown that polypharmacy is an independent risk factor for falls. Drugs are significant risk factors for falls, and stopping drugs that increase the risk of falling is an effective intervention to prevent falls (5, 16, 25). In 13 of the 19 studies evaluated in a meta-analysis, no relation was found between polypharmacy and falling (2). As seen in other meta-analyses (26, 27), polypharmacy was not a risk factor for falls in our study. Although the relationship between polypharmacy and falls is controversial, many studies have shown the relationship between recurrent falls and polypharmacy. However, in our study, no association was found between polypharmacy and recurrent falls. When we look at the reasons for this difference, we found that the rate of people reporting recurrent falls in other studies is less than our study (12.2%, 28%, 19.7%, and 22% vs. 48.5%) (4, 6, 8, 12). Therefore, as the sample size has increased, the relationship seen in others may have disappeared.
Some studies have found that the inappropriate use of drugs that cause falling was more critical in increasing the risk of falling than the number of drugs used by older adult patients (3, 28–30). In some studies, this relationship between fall and PIM usage was not found (24, 31). In research, there was no difference in terms of falls between patients using PIMs, which increased the risk of falling and those who did not (31) In a study involving 99 people, 11 types of drugs (ibuprofen, gabapentin, sertraline, alprazolam, ranitidine, zolpidem) were determined as PIMs. At the same time, there was no relationship between PIMs use and falling and recurrent falling, and there was no relationship between recurrent falls and either polypharmacy or PIM (24). In the present study, although polypharmacy was high, the PIM rate was found in only 29.2% of the patients. No significant correlation was found between the presence of PIMs and drug types on the Beers criteria and falling and recurrent falling.
Drug classes that have been associated with an increased risk of falls include the following: antihypertensive agents, sedatives and hypnotics, neuroleptics and antipsychotics, antidepressants, benzodiazepines, and nonsteroidal anti-inflammatory drugs (NSAIDs). In the studies conducted, a direct relationship between some drug groups and falling was observed. A two-way relationship was found between fall risk increase drugs (FRID) and polypharmacy in one study. While the prevalence of FRIDs was higher in patients with polypharmacy, polypharmacy was also more common in patients with FRIDs (25). Using FRIDs was an increased risk of falls (32). When we looked at the specific drug groups, NSAIDs, benzodiazepine, antidepressants, hypnotics, opioids, and antihypertensive drugs were associated with falls in some research (2, 26, 33). However, nine of 13 studies showed no association between NSAID use and falls (34). In a meta-analysis, opioid and antiepileptic usage were significantly associated with an increased risk of falling. Still, NSAIDs, proton pump inhibitors, anti-dementia drugs, antiplatelets, antiparkinsonian drugs, analgesics were not associated with falling (16). In another study, no significant relationship was observed between 23 drug types and falls (24). Antipsychotic, antidepressant, analgesic, antiparkinsonian, acid-related, nasal preparation, and ophthalmological drugs were all associated with recurrent falls (17). Formiga et al. found that individuals with recurrent falls have more polypharmacy and use of neuroleptics (12). In a cohort study (13), only oral antidiabetic usage was related to recurrent falls. We evaluated the relationship between oral antidiabetic drugs and recurrent falling, and we did not find any association between them. As shown in a study, the use of psychoactive drugs defined as PIMs based on the Beers criteria increases the risk of falling by up to 20% (35). Anderson et al. found a relationship between using only antidepressants and recurrent falls among antipsychotic, antianxiety, antidepressant, or diuretic medications (9). In a study involving community-dwelling older adults, the relationship between recurrent falls and SSRI use, moderate dosage, and short duration of use was shown (36). As in our study, Chiu et al. did not establish a relationship between anticoagulant use and recurrent falls (37). Also, in a meta-analysis, the use of psychotropic drugs increased the risk of falling in some studies, while in others, it was found not to increase the risk of falling (2). To our surprise, we found no association between the benzodiazepine, antipsychotics, antidepressants (tricyclic antidepressants, serotonin reuptake inhibitors, serotonin-noradrenalin reuptake inhibitors, and NSAIDs with recurrent falls. The reason for this may be the restriction on the use of hypnotic drugs and on prescribing imposed on individual physicians in Turkey by the Ministry of Health. Also, the participants may have forgotten to notify them that they can take NSAIDs without a prescription; the non-prescription drugs are not seen in the Medulla system, so these drugs were not included.
In our research, ACE-I usage was an increased risk of recurrent falls. It is known that antihypertensive drugs can cause falls through several mechanisms. They increase the risk of falling by causing sudden blood pressure drops, orthostatic hypotension, and electrolyte imbalance (38, 39).
In this study, when the relationship between recurrent falls and advanced age was examined, we demonstrated that older age increases recurrent falls, as seen in other studies (28, 32, 40). To date, many studies have shown that there is a relationship between falls and walking speed (5, 39). Patients with decreased walking speed have an increased risk of falling, but we did not investigate their relationship in the present study. Few studies examine the relationship between muscle strength and falling. In some of these studies, people with recurrent falls had low HGS values (6, 40). Sarcopenia is known to increase the risk of falling. People with low HGS are probable sarcopenic (21). Our study showed a strong relationship between low HGS and recurrent falls, which is one of the sarcopenia criteria affecting muscle strength in falling.
In our study, there were some limitations. One of the limitations was that the presence of drug-drug interaction had not been studied. While some drugs may not increase the risk of falling alone, they increase the risk of falling significantly due to their accumulated effects when used with drugs from another group. Over-the-counter drugs, nasal drugs, ophthalmological drugs, and the use of herbal medicines are not included in the study. Since only outpatient participants were included, the study population may be healthier than the older adult population in the community. Furthermore, the study was designed as a cross-sectional study; it may have been limited in showing the relationship between fall risk factors and recurrent falling.