Dr Ruma Dutta explores causes of falls in older people and explains how addressing orthostatic hypotension and reviewing medications could help to reduce risks

Falls and injuries from falls are a common and serious problem for older people. Individuals aged over 65 years are at highest risk, with 30% of people older than 65 years, and 50% older than 80 years, falling at least once a year.1 Falls are estimated to cost the NHS more than £2.3 billion per year and impact negatively on the quality of life of patients and their family/carers.1 This article focuses on the identification, assessment, and management of two interconnected causes of falls that can be performed by a medical professional, and which can reduce the occurrence of falls in susceptible older patients.

Healthcare professionals should routinely ask people aged 65 years and older about:1

  • whether they have fallen in the past year
  • the frequency, context, and characteristics of any fall(s).

If people are thought to be at risk of falling, or have fallen, the healthcare practitioner should observe them for balance and gait deficits and assess their ability to benefit from interventions to improve strength and balance.1

Patients at particularly high risk of falling include people with a history of:1–8

  • multiple unexplained falls
  • fragility fractures
  • attendance at Accident and Emergency (A&E), or by ambulance following a fall
  • two or more intrinsic risk factors for a fall (e.g. muscle weakness, poor balance, visual deficit, cognitive impairment, arthritis, syncope).

Also at risk of falls are people who:1-8

  • take more than three medications
  • have fallen in hospital
  • live in a care home
  • have a fear of falling.

Among 26 older people living in the community who attended an A&E department for falls in Newcastle over a 4-week period, balance abnormalities were found in 20%, gait abnormalities in 36%, orthostatic hypotension in 20%, and culprit medication in 40%.9 In nursing home residents, orthostatic hypotension is reported to be an independent risk factor for recurrent falls.10

A multifactorial risk assessment should be used as the basis for instituting a multiple risk factor intervention programme. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service.1 Medical components of the assessment include diagnosing syncope and assessing basic cardiac status (i.e. heart rate, rhythm and postural blood pressure [BP]), as well as other examinations.1

Interventions often also include:1

  • evidence-based exercise programme for strength and balance training
  • home hazard assessment and intervention
  • vision assessment and referral.

Orthostatic hypotension is defined as a fall in systolic BP of at least 20mmHg within 3–5 minutes of assuming the head upright posture (which may or may not cause symptoms).11,12 Its prevalence is 8.3%–34% in older populations,13–15 up to 39% in geriatric inpatients,16 and 31% in frail elderly people presenting with syncope.17

The commonest cause of orthostatic hypotension is medication (66%).18 Other secondary causes include:20–32

  • autonomic neuropathy in diabetes
  • Parkinson’s syndromes
  • Addison’s or multiple sclerosis
  • anaemia
  • deconditioning
  • hypovolaemia
  • hypokalaemia
  • varicose veins.

Orthostatic hypotension is usually precipitated by sudden postural/height change but can also result from hunger; exercise; fatigue; hot environments; large, high-fat meals; alcohol; straining (e.g. at stool).20–32

Symptoms and signs of orthostatic hypotension

Symptoms and signs of orthostatic hypotension arise from organ hypoperfusion. Organs furthest above the horizontal are most likely to be affected. Central nervous system symptoms are common and include loss of consciousness; dizziness; impaired balance; low mood; tunnel vision; blurred vision. Cardiovascular involvement can cause angina or palpitations; lung involvement causes panting or hyperventilating. Involvement of the gastrointestinal tract results in nausea or vomiting, and of the kidneys, in oliguria. Skin involvement can cause pallor, sweating, and acrocyanosis. General symptoms include weakness; lethargy; chronic fatigue; yawning; fearfulness; insomnia; headache; coat-hanger ache; buttock ache; as well as falls.20–32

A thorough history about falls would therefore include:20–32

  • frequency of falls
  • circumstances, including any precipitating factors
  • symptoms preceding the episode
  • eye-witness accounts of the episode
  • post-episode symptoms
  • the patient’s appearance during the episode.

It is also necessary to take a complete medication history, including the temporal relationship of any medication to the onset of symptoms.

Measuring blood pressure

Blood pressure should first be measured while the patient is lying supine (i.e. on their back) over a 10-minute period or until blood pressure is stable, and then continuously/repeatedly over 3–5 minutes while they are standing. The lowest BP in each position is used. When taking BP, remember to keep the instrument at the level of the patient’s heart both when they are lying and when they are standing. Blood pressure should not be taken after the patient has ingested caffeine (because caffeine can cause a rise in blood pressure), or if they are in a cold environment (because cold can induce peripheral vasconstriction).

Orthostatic hypotension can also be indirectly diagnosed from ambulatory BP monitoring, where it may demonstrate that night-time BP (supine) measurements are higher than daytime measurements.

Managing orthostatic hypotension

Once orthostatic hypotension has been diagnosed, management principles are to treat the cause of orthostatic hypotension, aim for symptom control (except in diabetic neuropathy, where preventing death from cardiovascular causes is the priority), and improve standing time and function, rather than to achieve upright normotension, which can lead to supine hypertension.19

The above outcomes can be achieved by combinations of the three methods of avoiding triggers and orthostatic stress, that is, by increasing:

  • venous return
  • blood volume
  • blood pressure.

NICE Clinical Guideline 127 on Hypertension: clinical management of primary hypertension in adults recommends referring the patient to a specialist if symptoms persist.20 If the patient is referred, other proven falls and bone health interventions outside the scope of this article would then also be addressed.

Non-pharmacological interventions

Non-pharmacological management of orthostatic hypotension includes advice on avoiding:21–32

  • sudden head-up postural change (especially first thing in the morning)
  • hunger
  • dehydration
  • excessive heat
  • large meals (especially with alcohol)
  • straining.

The patient should undertake regular, steady, gentle, isometric exercises like swimming to prevent deconditioning.21–32 People with orthostatic hypotension should:21–32

  • adopt strategic ‘getting-up’ strategies
  • increase their non-caffeinated fluid intake to >2 litres/day (about 3 litres/day if they weigh more than 75 kg)
  • eat several small meals a day
  • drink caffeine on rising and after meals
  • lie propped up at night with a head-up tilt of 15°–20° (pillow height 20cm–30cm).

They should not stand still for prolonged periods and should undertake gentle rocking or stretching if they need to do so. If not contraindicated, salt intake can be increased, for example by eating salty snacks. The wearing of full-length European Grade II–III compression hosiery or abdominal binders during the day improves venous return but these can be difficult to get on, especially for people with arthritic hands.21–28

Pharmacological interventions

Pharmacological management may be needed if the above measures fail. Salt tablets (slow sodium 2g–10g/day) may be helpful. Laxatives may be needed to prevent constipation. The first step, however, would be to modify existing culprit medication. This could be by cessation, reduction, or change of a medication to a longer-acting version or a different medication without hypotensive effects. Aim for a target clinic BP below 150/90 mmHg in people aged 80 years and over with treated hypertension.20

Despite these measures, it may on rare occasions be necessary to prescribe BP-elevating medication. In the UK, there are no clinically appropriate licensed drugs. The benefits must be weighed against the possible risks. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information.29

The principal therapeutic effects of BP-elevating drugs are on vessel tension and on blood volume. The most important agents are sympathomimetic agents (directly or indirectly acting), dihydroergotamine (a partial alpha-adrenoceptor antagonist), and fludrocortisone (which increases blood volume).

Fludrocortisone, trialled with a starting dose of 100 µg and a maximum dose of 200 µg, is a potent mineralocorticoid and can cause oedema, headache, low levels of potassium and magnesium, supine hypertension, and weight gain.28,30–32 Midodrine, which is always initiated in secondary care, does not have UK marketing authorisation for postural hypotension or any other indication, but can be effective. NICE has published an evidence summary on the unlicensed or off-label use of midodrine for treating postural hypotension in adults.33 Commencing doses may be as low as 2.5 mg three times a day but can be increased to 10 mg three times a day. All doses should be taken by mid-afternoon.30–32

All people who fall should have their drug burden reviewed with a view to how the drugs they are taking might cause falls.34 A drug review would look at the drug’s indication, when it was started, whether it is effective, and whether there are any side-effects. An attempt should be made to reduce the number of medications and dosages, to ensure that they are appropriate, and that they do not cause undue side-effects or undesirable interactions.35

Potentially inappropriate prescribing in older patients can be reduced. Guidance on this topic includes the US Modified Beers criteria (2003), which identify 48 such classes of drugs.36,37 In the UK, the STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) tool identifies 65 clinically significant criteria for potentially inappropriate prescribing in older people (STOPP) and 22 evidence-based prescribing indicators for commonly encountered diseases in older people (START).37–39

The FallSafe project,40 compiled for hospital inpatients who have fallen, provides comprehensive guidance for practitioners in reducing medication in people who fall, and has been approved by the British Geriatrics Society. See Medicines and falls in hospital. Guidance sheet,35 available at www.rcplondon.ac.uk/resources/falls-prevention-resources and Tables 1 and 2.

Falls can be caused by almost any drug that acts on the brain or the circulation. Older patients are more sensitive to the effects of medication. Falls may be due to recent changes in medication but are usually caused by medicines that have been taken for some time.

In weighing up the risks of a patient falling against their risks of stopping long-standing medication, it is helpful to remember that:34

  • in a person aged 85 years, there is a 1% risk of dying from a fall
  • the risk of falling increases with a systolic BP at or below 110 mmHg in older people
  • the risk of an older person falling or having syncope will be reduced by 50% if culprit medications that are known to be high or medium risk of causing falls are stopped (see Table 2).35

It is useful to bear in mind that heart failure in most older patients is not due to systolic dysfunction, in which angiotensin-converting enzyme inhibitors and beta blockers do improve survival.34 In older fallers, NICE recommends stopping nitrates, calcium channel blockers, and other vasodilators. If there is no evidence of congestion, diuretics should be reduced. If problems persist, seek specialist advice.35,41

Usually the mechanism leading to a fall caused by medication is one or more of:35

  • sedation (with slowing of reaction times and impaired balance)
  • hypotension
  • bradycardia, tachycardia, or syncope.

Table 1 shows drugs that are high to medium risk for causing falls by sedation.35 Stopping these drugs can reduce falls, but extra caution is needed with long-term users of benzodiazepines and drugs in the zopiclone group. Withdrawal of drugs for Parkinson’s requires specialist input.

Table 2 (here) shows medications that that are at high to medium risk for causing falls due to hypotension (either alone or in combination).35 A fuller version of Tables 1 and 2 (which also shows drugs that are possible causes of falls) is available in the FallSafe Medicines and falls in hospital. Guidance sheet.35

In systolic cardiac failure, angiotensin-converting-enzyme (ACE) inhibitors and beta blockers have a survival benefit and should be maintained whenever possible (see Table 2).34

Falls reduction requires a multidisciplinary approach, including evidence-based exercises, bone protection, and the measurement of the patient’s blood pressure in both lying and standing positions. Orthostatic hypotension is often under-detected but can be managed by a combination of reducing an existing culprit drug burden, avoiding known precipitants, and other measures.

Table 1: Drugs acting on the brain (psychotropic drugs) that commonly cause falls alone or in combination by sedation35
Medication group Commonly used medications within the group Effects on falls risks
Sedatives: benzodiazepines Temazepam, nitrazepam, diazepam, lormetazepam, chlordiazepoxide, flurazepam, lorazepam, oxazepam, clonazepam Drowsiness, slow reactions, impaired balance.
Caution in patients who have been taking them long term.
Sedatives: ‘Zs’ Zopiclone, zolpidem Drowsiness, slow reactions, impaired balance.
Sedating antidepressants (tricyclics and related drugs) Amitriptyline, dosulepin, imipramine, doxepin, clomipramine, lofepramine, nortriptyline, trimipramine
Mirtazapine, mianserin, trazodone
All have some alpha blocking activity and can cause orthostatic hypotension.
All are antihistamines and cause drowsiness, impaired balance and slow reaction times.
Double the rate of falling.
Monoamine oxidase inhibitors (MAOIs) Phenelzine, isocarboxazid, tranylcypromine MAOIs are little now used; all (except moclobemide) cause severe orthostatic hypotension.
Drugs for psychosis and agitation Chlorpromazine, haloperidol, fluphenazine, risperidone quetiapine, olanzapine All have some alpha receptor blocking activity and can cause orthostatic hypotension.
Sedation, slow reflexes, loss of balance.
Selective serotonin reuptake inhibitor (SSRI) antidepressants Sertraline, citalopram, paroxetine, fluoxetine Cause falls as much as other antidepressants in population studies.
Several population studies have shown that SSRIs are consistently associated with an increased rate of falls and fractures, but there are no prospective trials. The mechanism of such an effect is unknown. They cause orthostatic hypotension and bradycardia only rarely as an idiosyncratic side effect. They do not normally sedate. They impair sleep quality.
Serotonin and norepinephrine reuptake inhibitor (SNRI) antidepressants
A combination of an SSRI and a noradrenaline re-uptake inhibitor
Venlafaxine, duloxetine As for SSRIs but also commonly cause orthostatic hypotension (through noradrenaline re-uptake blockade).
Opiate analgesics All opiate and related analgesics—codeine, morphine, tramadol Sedate, slow reactions, impair balance, cause delirium.
Anti-epileptics Phenytoin Phenytoin may cause permanent cerebellar damage and unsteadiness in long term use at therapeutic dose.
Excess blood levels cause unsteadiness and ataxia.
Carbamazepine, phenobarbitone Sedation, slow reactions. Excess blood levels cause unsteadiness and ataxia.
Sodium valproate, gabapentin Some data on falls association.
Parkinson’s disease (PD): Dopamine agonists Ropinirole, pramipexole May cause delirium and orthostatic hypotension.
Parkinson’s disease (PD): MAOI-B inhibitors Selegiline Causes orthostatic hypotension. The subject of drugs and falls in PD is difficult, as falls are so common, and orthostatic hypotension is part of the disease. In general only definite drug related orthostatic hypotension would lead to a change in medication.
Muscle relaxants Baclofen, dantrolene Sedative. Reduced muscle tone. No falls data on muscle relaxants. Tend to be used in conditions associated with falls.
  • Key: red shading=high risk; orange shading=medium risk
  • There is good evidence that stopping these drugs can reduce falls.
  • * Taking such a medicine roughly doubles the risk of falling. There are no data on the effect of taking two or more such tablets at the same time.
  • Sedatives, antipsychotics, and sedating antidepressants cause drowsiness and slow reaction times. Some antidepressants and antipsychotics also cause orthostatic hypotension.
  • * Campbell A, Robertson M, Gardner M et al. Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized, controlled trial. J Am Geriatr Soc 1999; 47: 850–853.
  • Darowski A, Chambers S and Chambers D. Antidepressants and falls. Drugs and Aging 2009; 26 (5): 381–394.
  • Adapted from: Darowski A, Dwight J, Reynolds J. Medicines and falls in hospital. Guidance sheet. Oxford, 2011. FallSafe falls prevention resource. The full version of this table and other FallSafe guidance is available at: www.rcplondon.ac.uk/resources/falls-prevention-resources (accessed 27 May 2014). By kind permission.
Table 2: Drugs acting on the brain (psychotropic drugs) that commonly cause falls alone or in combination by sedation35
Medication group Commonly used medications within the group Effects on falls risks
Alpha receptor blockers Doxazosin, indoramin, prazosin, tamsulosin, terazosin, alfuzosin Used for hypertension or for prostatism in men. They commonly cause severe orthostatic hypotension. Stopping them may precipitate urinary retention in men.
Sedating antidepressants See ‘sedating antidepressants’ in the ‘drugs acting on the brain’ table.
Orthostatic hypotension.
Drugs for psychosis and agitation See ‘drugs for psychosis and agitation’ in the ‘drugs acting on the brain’ table.
Orthostatic hypotension.
Centrally acting alpha 2 receptor agonists Clonidine, moxonidine May cause severe orthostatic hypotension.
Sedating.
Thiazide diuretics Bendroflumethiazide, chlorthalidone, metolazone Cause orthostatic hypotension, weakness due to low potassium.
Hyponatraemia.
Loop diuretics Furosemide, bumetanide Dehydration causes hypotension. Low potassium and sodium
Angiotensin converting enzyme inhibitors (ACEIs) Lisinopril, ramipril, enalapril, captopril, perindopril These drugs rely almost entirely on the kidney for their elimination and can accumulate in dehydration or renal failure.
Fosinopril, trandolapril, quinapril Excreted by liver and kidney.
Symptomatic hypotension in systolic cardiac failure
  • ACEIs and beta blocker have a survival benefit in systolic cardiac failure and should be maintained whenever possible.
  • NICE recommends: stop nitrates, calcium channel blockers and other vasodilators. If no evidence of congestion, reduce diuretics. If problem persists, seek specialist advice.
  • The mortality risk from a fall at age 85 is about 1% per fall. The frequency of falls determines the balance between risk and benefit.
Most cardiac failure in older people is diastolic (preserved left ventricular function). ACEIs and beta blockers have little survival benefit in diastolic failure.
Angiotensin receptor blockers (ARBs) Losartan, candesartan, valsartan, irbesartan, olmesartan, telmisartan, eprosartan May cause less orthostatic hypotension than ACEIs.
Excreted by liver and kidney.
Beta blockers Atenolol, sotalol—renally excreted. May accumulate. Can cause bradycardia, hypotension, carotid sinus hypersensitivity, orthostatic hypotension and vasovagal syndrome.
Bisoprolol, metoprolol, propranolol, carvedilol, timolol eye drops
Antianginals Glyceryl trinitrate (GTN) A common cause of syncope due to sudden drop in blood pressure.
Isosorbide mononitrate, nicorandil Cause hypotension and paroxysmal hypotension.
Calcium channel blockers that only reduce blood pressure Amlodipine, felodipine, nifedipine, lercanidipine Cause hypotension and paroxysmal hypotension.
Calcium channel blockers which slow the pulse and reduce blood pressure Diltiazem, verapamil May cause hypotension or bradycardia.
Other antidysrhythmics Digoxin, amiodarone, flecainide May cause bradycardia and other arrhythmias.
Data on digoxin and falls probably spurious due to confounding by indication.
  • Key: red shading=high risk; orange shading=medium risk; green shading=NICE guidelines
  • Maintaining consciousness and an upright posture requires adequate blood flow to the brain. This requires an adequate pulse and blood pressure. In older people, a systolic blood pressure of 110 mmHg or below is associated with an increased risk of falls.
  • Any drug that reduces the blood pressure or slows the heart can cause falls (or feeling faint or loss of consciousness or ‘legs giving way’).
  • * In some patients the cause is clear—they may be hypotensive, or have a systolic drop on standing. Others may have a normal blood pressure lying and standing, but have syncope or pre-syncope from carotid sinus hypersensitivity or vasovagal syndrome. Stopping cardiovascular medication reduces syncope and falls by 50%, and reduces the prevalence of these four syndromes.
  • † ‡
  • * Darowski A and Whiting R. Cardiovascular drugs and falls. Reviews in Clinical Gerontology 2011; 21 (2) 170–179.
  • Van der Velde N, van den Meiracker A, Pols H et al. Withdrawal of fall-risk-increasing drugs in older persons: effect on tilt-table test outcomes. J Am Geriatr Soc 2007; 55: 734–739.
  • Alsop K, MacMahon M. Withdrawing cardiovascular medications at a syncope clinic. Postgrad MJ 2001; 77: 403–405.
  • Adapted from: Darowski A, Dwight J, Reynolds J. Guidance sheet. Medicines and falls in hospital. Oxford, 2011. FallSafe falls prevention resource. The full version of this table and other FallSafe guidance is available at: www.rcplondon.ac.uk/resources/falls-prevention-resources (accessed 27 May 2014). By kind permission.
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