Psychotropic Medications and falls

Vitamin D for fall and fracture

prevention

Leon Flicker

Western Australian Centre for Health & Ageing CMR,

School of Medicine and Pharmacology, UWA.

Department of Geriatric Medicine Royal Perth Hospital

Key concepts in age related

change • Contributing factors

– Impaired physiological function possibly only

due to disease and drugs

– Lifestyle and inactivity

• Intrinsic and Extrinsic Factors

• Multiple aetiology and multiple pathology

Stability and Fall ThresholdStability and Fall Threshold

Cross country walking

Changing light bulbs

Gardening

Cooking / shopping

Stability

Age

From being at risk to falling

• Not a linear relationship between

impaired function and disability

• Threshold effect: stability and daily

activities

• Instability is a key component of frailty

Risk factors RR/OR

•Medications associated with increased risk – ≥4 medications

– Psychotropic drugs (1.7)

– Includes SSRIs

– In women

– Class 1a antiarrhythmics (1.6)

•Why do these medications increase the risk

of falls?

Vitamin D levels Predicts Falls in Older People in

Residential Care Cox Proportional Hazards Model (Ratio [95% CI])

Multivariate

Log 25D 0.74 [0.59-0.94]

Log Weight 0.51 [0.29-0.88]

‘Wandering’ 1.51 [1.08-2.10]

Past Colles 1.99 [1.28-3.08]

Neuroleptics 1.54 [1.16-2.04]

AMTS 4-7 1.37 [1.03-1.82]

AMTS 1-3 0.95 [0.69-1.31]

Age, antidepressant & benzodiazepine use and past hip fracture were

not significant predictors.

Correlation between AMTS and 25D level = 0.23 p < 0.001

2008

Fall risk - predisposition

Neuromuscular

change

Inactivity

Impaired strength

and balance Fall risk

Knee arthritis

Antidepressants Postural

hypotension

Poor vision

Elderly woman living alone during the winter

Fear and Gait performance

• Gait changes in old age are also an

adaptation to a range of factors

• Gait speed – predictor of falls and correlates with poor balance

– associated with

• decreased muscle strength

• fear of falling and “cautious gait” syndrome

• cardiorespiratory failure

Falls prevention - What works?

• Multidisciplinary assessment of high risk populations *

• Expedited cataract surgery *

• Strength and balance training in high risk populations *

• Group exercises with functional balance exercises *

• Withdrawal of centrally acting medications *

• Cardiovascular assessment and intervention of unexplained fallers *

• Comprehensive geriatric assessment in nursing homes

• Targeted interventions in hospitals

?? What works in RCFs and people with dementia *Community populations

Vitamin or Prehormone

• In most parts of the world the predominant

source of vitamin D3 is endogenous production

by the action of ultraviolet light on 7-dehydrochol

in the skin.

• Sunlight exposure cannot produce vitamin D

intoxication

• There is no biomarker that is more confounded

by general heath than circulating levels of

vitamin D as it represents general outdoor

activity

Vitamin D metabolism.

Thacher T D , Clarke B L Mayo Clin Proc. 2011;86:50-60

© 2011 Mayo Foundation for Medical Education and Research

Table 1. Classification of Vitamin D–Deficient Status

© 2008 American Society for Bone and Mineral Research

From the Primer on the Metabolic Bone Diseases

and Disorders of Mineral Metabolism, 7th Edition.

www.asbmrprimer.org

Figure 1

Figure 1 The pathway from vitamin D deficiency to falls and fractures. © 2008 American Society for Bone and Mineral Research

From the Primer on the Metabolic Bone Diseases

and Disorders of Mineral Metabolism, 7th Edition.

www.asbmrprimer.org

Vitamin D deficiency in older people

• Old people are more likely to have

relative vitamin D deficiency due to – Decreased production of D3 within the dermis

(MacLaughlin & Holick 1985),

– Inadequate exposure to sunlight (Reid et al. 1986),

and

– Decreased renal capacity for production of 1,25-

dihydroxyvitamin D (Tsai et al. 1984).

– Decrease in intestinal responsiveness to 1,25-

dihydroxyvitamin D occurring with age (Ebeling et

al. 1992), may potentiate the reduced availability of

1,25-dihydroxyvitamin D.

Vitamin D and Calcium to Prevent Hip Fractures in

Older Women The Best Evidence (Chapuy NEJM 1992)

3270 women - mean age 84

– Living in nursing homes and apartments for the elderly

– Treated group 1.2 g calcium and 800 IU of Vitamin D3

– Control group placebo

• Followed for 18 months

• In active group - 32% less non vertebral fractures

• 43% less hip fractures

• A subgroup of 142 women followed intensively

– mean PTH 6.0 to 3.3 pmol/l

– mean 25(OH) D 40 to 105 nmol/l (NR 38)

– Only a 1% difference in femoral neck BMD

• Community dwelling older people with

dementia have lower 25-hydroxyvitamin

(25-OHD) levels than age matched

controls (Kipen et al JAGS 1995;43:1088)

• Low concentration of 25-OHD have also

been associated with objective measures

of abnormal motor performance, proximal

muscle weakness, increased body sway

and impaired postural and dynamic

balance Glerup et al, Calc Tiss Int 2000;66:419; Pfeifer et al,

JBMR 2000;15:1113.; Dhesi et al JBMR 2002;17:891; Bischoff-

Ferrari et al, Arch Int Med 2006;166:424

Previous study of residential care in

Australia • The study spanned 3 states of

Australia - Victoria, NSW and

Western Australia.

• 60 hostels, 667 residents and

89 nursing homes, 953

residents participated in cohort

study for 6 months follow-up

• (JAGS 2003; 51:1533)

• Subsequently 625 subjects

participated in a RCT of

1000IU/day vitamin D

supplementation

• (JAGS 2005; 53:1881)

Vitamin D levels Predicts Falls in Older People in

Residential Care Cox Proportional Hazards Model (Ratio [95% CI])

Multivariate

Log 25D 0.74 [0.59-0.94]

Log Weight 0.51 [0.29-0.88]

‘Wandering’ 1.51 [1.08-2.10]

Past Colles 1.99 [1.28-3.08]

Neuroleptics 1.54 [1.16-2.04]

AMTS 4-7 1.37 [1.03-1.82]

AMTS 1-3 0.95 [0.69-1.31]

Age, antidepressant & benzodiazepine use and past hip fracture were

not significant predictors.

Correlation between AMTS and 25D level = 0.23 p < 0.001

Vitamin D supplementation reduces incidence of falls

in residents whose 25D levels were 25-90nmol/l

0 182 365 547 730

0.00

0.25

0.50

0.75

1.00

Placebo

Vit D supplement

No at risk

Placebo

Vit D supplement

166

166

99

116

73

90

48

45

Pro

port

ion

271

269

Kaplan-Meier Estimates of Cumulative Hazard for Falls for

Subjects whose Compliance is Greater than or Equal 50%

Figure 2

0 182 365 547 730

0.00

0.25

0.50

0.75

1.00

Placebo

Vit D supplement

No at risk

Placebo

Vit D supplement

166

166

99

116

73

90

48

45

Pro

port

ion

271

269

Kaplan-Meier Estimates of Cumulative Hazard for Falls for

Subjects whose Compliance is Greater than or Equal 50%

Figure 2