Use of psychoactive medications in older adults

Use of psychoactive medications in older adults

Emily Hulke, PharmD, Goodrich Pharmacy

Background: Falls are the leading cause of injuries among adults aged 65 and older, with three million older adult patients per year treated in emergency departments for fall injuries. The Centers for Disease Control (CDC) reported that in 2015, the total medical costs for falls was over $50 billion with Medicare and Medicaid covering 75% of these costs. Both intrinsic risk factors such as age and poor vision, and extrinsic factors including footwear and medication use can contribute to falls. Psychoactive medications, those that act primarily on the central nervous system, can cause side effects that increase the risk of falls by causing confusion, drowsiness, vision disturbances, and orthostatic hypotension. Examples of psychoactive medications include benzodiazepines, antipsychotics, anticonvulsants, opioids, and certain antidepressants. 

A study published by Landi et al. found that users of any psychoactive drugs had an increased risk of falls by approximately 47% [OR 1.47 95% CI 1.24-1.74] in community dwelling older adults. Additionally, Campbell et al. found that pharmacist-led discontinuation of psychoactive medications in older adults could reduce falls by 66%. Understanding the prevalence of psychoactive medication use and changes in use over time allows health professionals and policy makers to prioritize and evaluate the impact of reducing psychoactive medication use on older adult falls.

Evidence: A recent study was conducted to estimate the prevalence of psychoactive medication use in older adults in 2013 and compare it to previous estimates from 1996. The data source for this study by Haddad et al. was Cost and Use Data files from 2013 which combine Medicare claims data and survey data from the Medicare Current Beneficiary Survey. Participants were included if they were age 65 years or older, community-dwelling, and had a complete year of prescription use data. A total of 6,969 patients were looked at which represented 33,268,104 community-dwelling Medicare beneficiaries. A majority of the beneficiaries were 65-74 years of age (51.5%) and white (85.3%). There were seven classes of medications defined as psychoactive in the study: opioids, benzodiazepines, non-benzodiazepine sedative hypnotics, antipsychotics, anticonvulsants, tricyclic antidepressants (TCAs), and selective-serotonin reuptake inhibitors (SSRIs). Using data from the 2013 report, they found that 53.3% of community dwelling older adults age 65 and older used at least one psychoactive medication class known to increase fall risk, a significant increase from the 15% reported by Moxey et al. in 1996. Of those, 29.6% used medications from one psychoactive medication class, 14.5% used two classes, and 9.2% used three or more classes during the calendar year. The most frequently used classes were opioids (34.9%), benzodiazepines (15.4%), SSRIs (14.3%), and anticonvulsants (13.3%). The prevalence of use in 2013 was considerably higher compared to the 1996 data for all of these classes with the exception of TCAs.

Discussion and Clinical Impact: The use of psychoactive medication use rose substantially in older adults between 1996 and 2013. Although the data used for this study is slightly outdated, it still shows that the use of psychoactive medications by older adults deserves greater attention.

With the use of psychoactive medications in older adults on the rise, health care providers should be sure to assess for medication that could be increasing fall risk during all patient encounters, especially in older patients. Pharmacists should continue to provide comprehensive medication management and serve as resources for providers by providing recommendations on how to reduce or discontinue high-risk medication use in older adults.The CDC’s Stopping Elderly Accidents and Injuries initiative recommends stopping high-risk psychoactive medications when possible and switching to a safer alternative. When this is not appropriate, the dose should be reduced to the lowest effective dose. Resources including the Screening Tool of Older Person’s Prescriptions (STOPP), AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, www.deprescribing.org, and anticholinergic burden indices can assist pharmacists in identifying potentially inappropriate medications that could be contributing to falls, including psychoactive medications, in older adults. 

References: 

  1. Centers for Disease Control and Prevention. Important Facts About Falls. https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html. Accessed August 11, 2019.

  2. Landi F, Onder G, Cesari M, Barillaro C, Russo A, Bernabei R; Silver Network Home Care Study Group. Psychotropic medications and risk for falls among community-dwelling frail older people: an observational study. J Gerontol A Biol Sci Med Sci. 2005;60(5):622-626.

  3. Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM. Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized controlled trial. J Am Geriatr Soc. 1999:47(7):850e853.

  4. Haddad YK, Luo F, Karani MV, Marcum ZA, Lee R. Psychoactive medication use among community-dwelling Americans. J. Am. Pharm. Assoc. 2019; 1-5. 

  5. Moxey ED, O’Connor JP, Novielli KD, Teutsch S, Nash DD. Prescription drug use in the elderly: a descriptive analysis. Health Care Financ Rev. 2003;24(4):127e141.