Cause or Effect? Selective Serotonin Reuptake Inhibitors and Falls in Older Adults: A Systematic Review

Abstract

A 2012 update of the Beers criteria categorizes selective serotonin reuptake inhibitors (SSRIs) as potentially inappropriate medications in all older adults based on fall risk. The application of these recommendations, not only to frail nursing home residents, but also to all older adults, may lead to changes in health policy or clinical practice with harmful consequences. A systematic review of studies on the association between SSRIs and falls in older adults was conducted to examine the evidence for causation. Twenty-six studies met the inclusion criteria. The majority of studies were observational and suggest an association between SSRIs and falls. The direction of the relationship – causation or effect- cannot be discerned from this type of study. Standardized techniques for determining likely causation were then used to see if there was support for the hypothesis that SSRI’s lead to falls. This analysis did not suggest causation was likely. There is no Level 1 evidence that SSRIs cause falls. Therefore, changes in the current treatment guidelines or policies on the use of SSRIs in older adults based on fall risk may not be justified at this time given the lack of an established evidence base. Given its significance to public health, well-designed experimental studies are required to address this question definitively.

Association of psychotropic drug use with falls among older adults in Germany. Results of the German Health Interview and Examination Survey for Adults 2008 – 2011 (DEGS1)

“…Our findings on the association between antidepressants use and falls or recurrent falls are also in line with results of other studies. Use of antidepressants, particularly SSRIs, has been consistently found to be associated with increased risks of falls and recurrent falls [40][41][42][43]. For example, in a longitudinal analysis of 2948 community-dwelling older adults followed-up for 7 years, antidepressant users, compared with nonusers, were observed to have a 48% greater likelihood of recurrent falls (OR 1.48, 1.12-1.96), particularly those taking SSRIs with an OR of 1.62 (1.15-2.28) [40].…”

Patterns of selective serotonin reuptake inhibitor use and risk of falls and fractures in community-dwelling elderly people: the Three-City cohort

“…This led to consider SSRIs as potentially inappropriate in older adults with a history of falls or fractures [18]. However, two recent systematic reviews concluded that evidence of causation was lacking due to the absence of a demonstrated mediating pathway between SSRIs and falls [19] or osteoporosis [20]. As the effects of antidepressants on falls and fractures in elderly people have never been evaluated in randomized clinical trials, only well-designed analyses of large population-based cohorts can help address these relationships, evaluating long-term effects and taking into account the temporality between exposure and outcome and the main confounders.…”

Should antidepressant medication be used in the elderly?

“…This complicates our ability to definitively identify causal relationships between antidepressant exposure and adverse outcomes. Although observational studies can identify medication adverse events, a prerequisite is that the adverse effect is distinct from the illness [19]. This is problematic in late-life depression that is associated with a range of medical illnesses across multiple organ systems [20].…”

“…Thus it is not always possible to disentangle what adverse health outcomes are related to antidepressant use and what are influenced by the occurrence and persistence of depression. This limits our ability to identify factors necessary to determine causality, such as temporality and specificity [19]. Moreover, conclusions from observational studies comparing depressed individuals taking antidepressants with nondepressed populations not taking antidepressants may not accurately identify true risks associated with drug exposure.…”