5 Drug Classes Linked to Increased Fall Risk Among Adults with COPD Near End of Life

An analysis of more than 8000 death certificates of persons with COPD has revealed that 65% were prescribed at least 1 fall-risk increasing drug (FRID) and that nearly one-third (30%) had a fall with injury 2 years before death.1

The study, published in Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation, found that compared with individuals who had not had a fall, the largest differences in prescriptions for those with falls were for anticonvulsants (35% versus 26%), antipsychotics (24% versus 13%), atypical antidepressants (28% versus 19%), tricyclic antidepressants (10% versus 5%), and SSRI antidepressants (27% vs 20%).1

The FRID classes prescribed most frequently across the 2 groups were antihypertensive agents, opioids, and benzodiazepines, according to the study.

The research team, led by Cara L. McDermott, PharmD, PhD, assistant professor in medicine in the Division of Geriatrics and Palliative Care at Duke University School of Medicine, reported further that the burden of FRID was higher among patients with an injurious fall, with a mean of 3.47 prescriptions across FRID classes compared with 2.85 prescriptions for FRIDs among those without an injurious fall. After adjustment for demographics and clinical conditions, logistic regression analysis showed that FRID burden was associated with greater odds of an injurious fall (odds ratio, 1.07 [95% CI, 1.04–1.09]).1

McDermott and colleagues noted that dementia was a more common comorbidity among those with a fall compared to those who did not fall, a finding in line with previous research showing that patients living with dementia are 2 to 3 times more likely to fall compared to patients without dementia, given the negative impact of reduced cognition on gait.2 “When possible, nonpharmacological alternatives to FRIDs, or using the lowest FRID dose possible for the shortest duration should be encouraged for patients living with both COPD and dementia," McDermott et al, wrote.

The retrospective cohort study was conducted using electronic health records (EHR) from a single health system in Washington State linked to death certificates of adults ages 40 or older with a diagnosis of COPD who died between 2014 and 2018. Investigators identified demographics, comorbidities, FRID burden, and the occurrence of injurious falls within the 2 years prior to death.1

Additional Findings

McDermott and colleagues also found that having a history of falls was significantly higher among the subgroup who had experienced an injurious fall before death (23%) compared to those without a fall (4%). When the researchers compared the presence of comorbidities between the groups with and without a fall, the average was 2.81 for the former and 2.46 for the latter. Only cancer was documented more frequently among those who did not have an injurious fall, ie, 26% among patients who fell versus 35% with no fall. The team also found that likelihood of an injurious fall was greater among individuals with COPD who were unmarried, were Black, and enrolled in Medicaid.

“In situations of polypharmacy, it can be difficult to decide which medications should be prioritized for dose reduction or discontinuation,” McDermott and colleagues wrote. While combinations of the drugs identified in the study pose even greater hazards for falls, they tend to be in the standard of care “toolbox,” they explained. The second and third most frequently prescribed medications were opioids and benzodiazepines, both appropriate in the context of COPD to alleviate breathlessness or anxiety. However, the authors stress the need for additional fall mitigation strategies for regular users of either class. They also recommended consideration of adjunctive nonpharmacologic interventions for individuals with COPD who are prescribed anticonvulsants, antipsychotics, and the 3 classes of antidepressant medications, all found more frequently in the list of prescriptions for those with injurious falls. They stress again that each class has an indication in the COPD population where pain, insomnia and depression are common.

Among the study’s limitations the authors noted the potential that patients had received care in other health care systems not included in the EHR used in the study.1 The team also could not include information on the severity of COPD or of documented comorbidities, or on home oxygen use. Data on medication orders could not be considered confirmation of prescriptions filled or taken.

“Fall-risk increasing drugs are commonly prescribed to people with COPD because they experience a high number of symptoms and conditions that indicate use of these drugs,” McDermott said in a COPD Foundation news release.3 “Pulmonologists and pharmacists need to collaborate with each other and with patients to develop fall prevention strategies and to increase patient safety by reducing the use of fall-risk increasing drugs and discussing other ways to mitigate fall risk."1

References

1. McDermott CL, Feemster LC, Engelberg, RA, et al. Fall risk and medication use near end of life among adults with chronic obstructive pulmonary disease. Chronic Obstr Pulm Dis. 2024; 11(6): 604-610. doi:http://doi.org/10.15326/jcopdf.2024.0551
2. Racey M, Markle-Reid M, Fitzpatrick-Lewis D, et al. Fall prevention in community-dwelling adults with mild to moderate cognitive impairment: a systematic review and meta-analysis. BMC Geriatr. 2021;21:689. doi:https://doi.org/10.1186/s12877-021-02641-9
3. Commonly prescribed medications increase fall risk and related injuries in people with COPD. News release. COPD Foundation. January 14, 2025. Accessed January 30, 2025. https://www.copdfoundation.org/About-Us/Press-Room/Press-Releases/Article/2090/Commonly-prescribed-medications-increase-fall-risk-and-related-injuries-in-peop.aspx