Depression, antidepressants and fall risk: therapeutic dilemmas-a clinical review

Key summary pointsAim To summarize the existing knowledge on fall risk associated with antidepressant use in older adults, including the underlying pathophysiology, and assist clinicians in (de-) prescribing antidepressants. Findings Untreated depression and antidepressant use both increase fall risk in older people. Antidepressants differ in fall-related side effect profile. They contribute to (or cause) falling through orthostatic hypotension, sedation/impaired attention, hyponatremia, movement disorders and cardiac toxicity. Although withdrawal of antidepressants is recommended in fall-prone elderly persons, physicians are frequently reluctant to deprescribe antidepressants. Practical resources and algorithms are available that guide and assist clinicians in deprescribing antidepressants. Message Insight in fall-related side effect profile of antidepressants, and clinical decision tools such as the STOPPFalls antidepressant withdrawal algorithm assist prescribers in rational (de-) prescribing decision making. Purpose The aim of this clinical review was to summarize the existing knowledge on fall risk associated with antidepressant use in older adults, describe underlying mechanisms, and assist clinicians in decision-making with regard to (de-) prescribing antidepressants in older persons. Methodology We comprehensively examined the literature based on a literature search in Pubmed and Google Scholar, and identified additional relevant articles from reference lists, with an emphasis on the most commonly prescribed drugs in depression in geriatric patients. We discuss use of antidepressants, potential fall-related side effects, and deprescribing of antidepressants in older persons. Results Untreated depression and antidepressant use both contribute to fall risk. Antidepressants are equally effective, but differ in fall-related side effect profile. They contribute to (or cause) falling through orthostatic hypotension, sedation/impaired attention, hyponatremia, movement disorder and cardiac toxicity. Falling is an important driver of morbidity and mortality and, therefore, requires prevention. If clinical condition allows, withdrawal of antidepressants is recommended in fall-prone elderly persons. An important barrier is reluctance of prescribers to deprescribe antidepressants resulting from fear of withdrawal symptoms or disease relapse/recurrence, and the level of complexity of deprescribing antidepressants in older persons with multiple comorbidities and medications. Practical resources and algorithms are available that guide and assist clinicians in deprescribing antidepressants. Conclusions (De-) prescribing antidepressants in fall-prone older adults is often challenging, but detailed insight in fall-related side effect profile of the different antidepressants and a recently developed expert-based decision aid STOPPFalls assists prescribers in clinical decision-making.

Automated summary

The use of antidepressants in older adults increases the risk of falls, but physicians are often reluctant to stop the prescription of these drugs. Practical resources and algorithms are available to guide and assist clinicians in this decision-making process.