Mortality related to falls has increased.

Years ago, elderly patients/residents with dementia were often dosed up with mogadon (nitrazepam), a fairly powerful sedative.

That doesn't happen now. I don't know whether sedation would make it more likely for someone to fall, due to dizziness, or less likely because they're too sleepy to move.

But, I do know that the risk of falls affects doctors' decisions about which drugs to prescribe. At least, here in the UK.
For that reason, I'm inclined to think that more people living with cognitive impairment for longer (due to higher rates of successfully treating serious diseases), coupled with the ban on using restraints, are big factors affecting the increase in falls and fall related injuries.

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“It’s easy to start meds, but it often takes a lot of time and effort to have patients stop taking them,” he said. Harried doctors may pay less attention to drug regimens than to health issues that seem more pressing, and patients can be reluctant to give up pills that seem to help with pain, insomnia, reflux and other common age-related complaints.
The Beers Criteria, a directory of drugs often deemed inadvisable for older adults, recently published recommendations for alternative medications and nonpharmacological treatments for frequent problems. Cognitive behavioral therapy for sleeplessness. Exercise, physical therapy and psychological interventions for pain.
“It’s a real tragedy when people have this life-altering event,” Dr. Steinman, co-chair of the Beers panel on alternatives, said of falls. He urged older patients to raise the issue of FRIDs themselves, if their doctors haven’t.
“Ask, ‘Do any of my medications increase the risk of falls? Is there an alternative treatment?’” he suggested. “Being an informed patient or caregiver can put this on the agenda. Otherwise, it might not come up.”


The New Old Age is produced through a partnership with KFF Health News.

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“The drugs that increase falls’ mortality are those that make you drowsy or dizzy,” he said.
Problematic drugs are numerous enough to have acquired an acronym: FRIDs, or “fall risk increasing drugs,” a category that also includes various cardiac medications and early antihistamines like Benadryl.
Such medications play a major role, agreed Dr. Thomas Gill, a geriatrician and epidemiologist at Yale University and a longtime falls researcher. But, he said, “there are alternative explanations” for the increase in death rates.
He cited changes in reporting the causes of death, for instance. “Years ago, falls were considered a natural consequence of aging and no big deal,” he said.
Death certificates often attributed fatalities among older people to ailments like heart failure instead of falls, making fall mortality appear lower in the 1980s and 1990s.

Today’s over-85 cohort may also be frailer and sicker than the oldest-old were 30 years ago, Dr. Gill added, because contemporary medicine can keep people alive for longer.
Their accumulating impairments, more than the drugs they take, could make them more likely to die after a fall.
Another skeptic, Dr. Neil Alexander, a geriatrician and falls expert at the University of Michigan and V.A. Ann Arbor Healthcare System, argued that most doctors have come to understand the dangers of FRIDs and prescribe them less often.
“Message delivered,” he said. Given the alarms sounded about opioids, about benzodiazepines and related drugs, and especially about opioids and benzos together, “a lot of primary care doctors have heard the gospel,” he said. “They know not to give older people Valium.”

Moreover, prescriptions for some fall-related drugs have already declined or hit plateaus, even as death rates because of falls have risen. Medicare data shows lower prescription opioid use beginning a decade ago, for example. Benzodiazepine prescriptions for older patients have slowed, Dr. Maust said.
On the other hand, the use of antidepressants and of gabapentin has increased.
Whether or not medication use outweighs all other factors, “nobody disputes that these agents are overused and inappropriately used” and contribute to the troubling increase in fall death rates among seniors, Dr. Gill said.
Thus, the ongoing campaign for “de-prescribing” — stopping the medications whose potential harms outweigh their benefits, or reducing their dosage.
“We know a lot of these drugs can increase falls by 50 to 75 percent” in older patients, said Dr. Michael Steinman, a geriatrician at the University of California, San Francisco, and co-director of the US Deprescribing Research Network, established in 2019.

For a while, walking the dog felt hazardous.
Earl Vickers was accustomed to taking Molly, his shepherd-boxer-something-else mix, for strolls on the beach or around his neighborhood in Seaside, Calif. A few years ago, though, he started to experience problems staying upright.
“If another dog came toward us, every single time I’d end up on the ground,” recalled Mr. Vickers, 69, a retired electrical engineer. “It seemed like I was falling every other month. It was kind of crazy.”
Most of those tumbles did no serious damage, though one time he fell backward and hit his head on a wall behind him. “I don’t think I had a concussion, but it’s not something I want to do every day,” Mr. Vickers said, ruefully. Another time, trying to break a fall, he broke two bones in his left hand.
So in 2022, he told the oncologist who had been treating him for prostate cancer that he wanted to stop the cancer drug he had been taking, off and on, for four years: enzalutamide (sold as Xtandi).

Among the drug’s listed side effects are higher rates of falls and fractures among patients who took it, compared with those given a placebo. His doctor agreed that he could discontinue the drug, and “I haven’t had a single fall since,” Mr. Vickers said.
Public health experts have warned of the perils of falls for older people for decades. In 2023, the most recent year of data from the Centers for Disease Control and Prevention, more than 41,000 Americans over 65 died from falls, an opinion article in JAMA Health Forum pointed out last month.
More startling than that figure, though, was another statistic: Fall-related mortality among older adults has been climbing sharply.
The author, Dr. Thomas Farley, an epidemiologist, reported that death rates from fall injuries among Americans over 65 had more than tripled over the past 30 years. Among those over 85, the cohort at highest risk, death rates from falls jumped to 339 per 100,000 in 2023, from 92 per 100,000 in 1990.

The culprit, in his view, is Americans’ reliance on prescription drugs.
“Older adults are heavily medicated, increasingly so, and with drugs that are inappropriate for older people,” Dr. Farley said in an interview. “This didn’t occur in Japan or in Europe.”
Yet that same 30-year period saw a flurry of research and activity to try to reduce geriatric falls and their potentially devastating consequences, from hip fractures and brain bleeds to restricted mobility, persistent pain and institutionalization.
The American Geriatrics Society adopted updated fall prevention guidelines in 2011. The C.D.C. unveiled a program called STEADI in 2019. The United States Preventive Services Task Force recommended exercise or physical therapy for older adults at risk of falling in 2012, 2018 and again last year.
“There’ve been studies and interventions and investments, and they haven’t been particularly successful,” said Dr. Donovan Maust, a geriatric psychiatrist and researcher at the University of Michigan. “It’s a bad problem that seems to be getting worse.”

But are prescription drugs driving that increase? Geriatricians and others who research falls and prescribing practices question that conclusion.
Dr. Farley, a former New York City health commissioner who teaches at Tulane University, acknowledged that many factors contribute to falls, including the physical impairments and deteriorating eyesight associated with advancing age; alcohol abuse; and tripping hazards in people’s homes.

But “there’s no reason to think any of them have gotten three times worse in the past 30 years,” he said, pointing to studies showing declines in other high-income countries.
The difference, he believes, is Americans’ increasing use of medications — like benzodiazepines, opioids, antidepressants and gabapentin — that act on the central nervous system.

I think all of these things are true. People are living longer, and tend to be more frail/ sick/ have balance problems/ may become more sensitive to meds as they age. There is a growing problem with staffing in SNF but even if SNF could ever have one to one staff to patient (impossible) falls could not be totally prevented.

For the healthier seniors, there is a clinical trial underway called FAST for Falling Safely Training. The purpose is to study if it is possible to train older adults to “fall safely” in addition to fall prevention.

https://pmc.ncbi.nlm.nih.gov/articles/PMC10130595/

This would be useless with dementia but might help others prevent or reduce injuries?

My mother (80, no dementia) has balance issues and will barely put her hands in front of her if she is about to fall. It’s like the instinct just isn’t there. She falls like a dead weight. In her case, there is no way she would do PT or any kind of training, but I still find it interesting if only for my future self.

I wish I had access to the article... prescription meds surely can be one of many variables.

I agree that a legal inability to keep fall-risk seniors in facilities (or at home!) safely secured combined with staffing issues is a big problem. When people have dementia they don't know that they can't (or shouldn't) walk without help, or at all. This included my 100-yr old Aunt with advanced dementia. Fell twice while in the presence of family caregivers. Then once escaped her bed at night and fell, breaking her hip. She wasn't on meds. She continued to attempt to get out of bed in rehab, since it isn't a NH. She passed in her sleep, probs a post-break clot complication.

I agree that people are living longer and so their balance naturally continues to degrade. In the 60s when Medicare and Medicaid came into existence, it opened up the use of facilities so a larger percentage of seniors are going into facilities where it is more difficult to monitor fall risk residents when they are understaffed.

Very happy to read the comment about falls in nursing homes. Unless you chain yourself to the patient there is very little that can be done. I admire caregivers in nursing homes. They do so much for so little. I certainly understand why they would choose to leave. Most families whose loved ones are in nursing homes have no idea the level of care required. Thank you for your post.

My beloved ex, 83 years old has Parkinson’s with dementia. In the last few months there has been a marked increase in him falling. He lives at home with a caregiver 4 hours per day. He does well when his caregivers are there but there are times when he is left alone and the falls happen. Because of the dementia he does not remember the falls. There have been more trips to the emergency room than you can count. The last fall caused bleeding in the brain and he is currently hospitalized. The situation is situation is stressful and untenable. Every fall, you hold your breath.

I worked in nursing homes many years ago for years .

I first hand saw the sharp increase in falls , ultimately resulting in death , when restraints used in beds and wheelchairs ( particularly Posey vests ) were taken away . A Velcro seatbelt on a wheelchair does not keep a confused patient , who forgot they can’t walk , safe in their wheelchair. They just rip the belt open and try to walk . I saw patients in wheelchairs with a useless lap buddy stand up and tip the whole chair over . A chair or bed alarm most likely just was a heads up that by the time we got to their room they would have already fallen and be on the floor. Then to be yelled at by family over it when we had to call to let them know. It’s why I and some of my coworkers left working in nursing homes 20 -25 years ago , btw. Being yelled at by family and staying late filling out incident forms , we burned out .
That’s the ugly truth of taking restraints away .

Many seniors fall due to balance problems in general , even without meds . Meds aren’t the only problem . People are also living longer unsteady on their feet at home , this is a factor as well .

Suzy
Thanks for the article.

A couple of things I thought were helpful.

Problematic drugs are numerous enough to have acquired an acronym: FRIDs, or “fall risk increasing drugs,” a category that also includes various cardiac medications and early antihistamines like Benadryl.

Ask, ‘Do any of my medications increase the risk of falls? Is there an alternative treatment?’” he suggested. “Being an informed patient or caregiver can put this on the agenda. Otherwise, it might not come up.”


Also the comments were informative, many from doctors. Two other fall risks mentioned,

Choice of glasses, progressive lens or bifocals. Sometimes better to have single lens eyewear depending on activity.

Several mentioned falling while walking their dog, mentioning leashes … tangles unexpected tugs from the dog.

Appatently Gabepentin is being over prescribed and difficult to get off of for some.