Deprescribing Intervention Ineffective at Preventing Falls Among Older Adults

Elizabeth A. Phelan, MD, MS

Credit: UW Medicine, Division of Gerontology and Geriatrics Medicine, University of Washington

A study found a deprescribing intervention embedded into the health system was no more effective than usual care in reducing medically treated falls among older adults.¹

“Ours may be the first deprescribing trial to document a reduction in [tricyclic antidepressants],” wrote investigators, led by led by Elizabeth A. Phelan, MD, MS, from the Division of Gerontology and Geriatrics Medicine at the University of Washington in Seattle. “System-level initiatives focusing on [tricyclic antidepressants] were not in place during the intervention period, which may explain why an effect of the intervention on [tricyclic antidepressants] was observed. The consistent pattern of higher [tricyclic antidepressant] discontinuation rates in the intervention arm suggests that the intervention influenced clinicians to focus on this class of medications for their deprescribing efforts.”

Central nervous system (CNS)-active medication, often prescribed to older adults, is considered high-risk since it may lead to adverse health outcomes, such as falls. A study published earlier this year found among older adults the prevalence of falls increases as the quantity of medication rises.² The prevalence rates of falls were 10.5%, 18.2%, 18.3%, and 19.8% in the no-medication, one-medication, comedication, and polypharmacy groups, respectively.

In the recent study, Phelan and colleagues sought to see if a deprescribing intervention delivered to community-dwelling older adults and their primary care clinicians would reduce the use of CNS-active medications, and as a result, shrink the number of medically induced falls.¹ The team conducted a cluster randomized, parallel-group clinical trial with 2367 older adults and their primary care clinicians. In total, eligible patients from 18 primary care practices were recruited from April 1, 2021, to June 16, 2022.

Participants were community-dwelling adults aged ≥ 60 years and were prescribed ≥ 1 medication from any of 5 targeted medication classes, including opioids, sedative-hypnotics, skeletal muscle relaxants, tricyclic antidepressants, and first-generation antihistamines), for ≥ 3 consecutive months. The mean age was 70.6 years, and more than half were female (63%). Most of the sample was White (87%), followed by Black or African American (3%), Hispanic (3%), Asian (2%), other race (2%), multiple races (2%), and 1% Native Hawaiian or Pacific Islander.

Participants had a mean of 2.2 chronic conditions. Only 3% were frail, and 29% sought medical care for a fall in the prior year. Most patients were prescribed 1 CNS-active medication, with the most popular ones being opioids (69%), benzodiazepines (14%), and TCAs (11%).

In the intervention group, participants received patient education and clinician decision support (n = 159; 14%). The control group received usual care (n = 206; 16%).

The primary outcome was medically treated falls. Secondary outcomes included medication discontinuation, sustained medication discontinuation, and dose reduction of any and each target medication. Furthermore, investigators evaluated safety by primarily examining serious adverse drug withdrawal events involving opioids or sedative-hypnotics.

After adjustment, the cumulative incidence rate of a first medically treated fall at 18 months was 0.33; 95% confidence interval [CI], 0.29 – 0.37) in the intervention room and 0.30 (95% CI, 0.27 – 0.34) in the usual group (estimated adjusted hazard ratio, 1.11; 95% CI, 0.94 – 1.31; P = .11).

Investigators observed significant differences favoring the intervention group for sustained discontinuation (intervention group, 0.23; 95% CI, 0.18 – 0.23 vs usual care group, 0.13; 95% CI, 0.09 - 0.17) and adjusted relative risk (intervention group, 1.79; 95% CI, 1.29 – 2.50) (P = .001). This was not seen for other medication classes.

Discontinuation of medications occurred at different time points. Compared to usual care, discontinuation was significantly greater in the intervention group for sedative-hypnotics at 9 months, antihistamines at 9 and 12 months, and first-targeted medication at 9 months.

In the usual care, sedative-hypnotic discontinuation rates ranged from 20% (adjusted rate, 0.20, 95% CI, 0.17 – 0.25) at 6 months to 46% (adjusted rate, 0.46, 95% CI, 0.42 – 0.50) at 15 months. Additionally, the usual care group had skeletal muscle relaxant discontinuation rates ranging from 39% (adjusted rate, 0.39, 95% CI, 0.33 – 0.47) at 6 months to 49% (adjusted rate, 0.49, 95% CI, 0.36 – 0.68) at 15 months.

As for safety, investigators observed an equal percentage of patients (7%) who died in the usual care and the intervention group. However, patients in the intervention group taking a benzodiazepine or an opioid were more likely to experience serious adverse drug withdrawal events (1% vs 0.4%).

“For health systems that attend to deprescribing as part of routine clinical practice, additional interventions may confer modest benefits on prescribing without a measurable effect on clinical outcomes, investigators concluded.

References

1. ^{Phelan EA, Williamson BD, Balderson BH, et al. Reducing Central Nervous System-Active Medications to Prevent Falls and Injuries Among Older Adults: A Cluster Randomized Clinical Trial. JAMA Netw Open. 2024;7(7):e2424234. Published 2024 Jul 1. doi:10.1001/jamanetworkopen.2024.24234}
2. ^{Yoshida Y, Ishizaki T, Masui Y, et al. Effect of number of medications on the risk of falls among community-dwelling older adults: A 3-year follow-up of the SONIC study. Geriatr Gerontol Int. 2024;24 Suppl 1:306-310. doi:10.1111/ggi.14760}