07 NOVEMBER 2007 ISSUE
Depression and falls interlinked
Ngaire Kerse
For older people both falls and depression are major health issues. Thus, it should not be surprising both conditions commonly coexist; so much so, a realisation of one should lead to an inquiry about the other. Every year up to 35 per cent of community dwelling older people will experience a fall, and the prevalence of depression in older people has been estimated to be between 10 and 25 per cent. For those with chronic illness or in residential care, prevalence of depression is higher (up to 40 per cent) and incidence of falls is very high.
Lorraine is an 80-year-old whom you have been treating for depression with fluoxetine for two years since she was widowed and her daughter moved away. She had become less willing to go out of the house and complained of not coping. She has got better and comes for a prescription renewal. Everything seems to be going okay so you renew her prescription.
People with depression are more likely to fall. The risk is quite high, with some studies showing a risk of falls up to three times greater for those who have depression. There is also an increased risk with use of antidepressants. These risks are independent of each other; people who are depressed fall more, regardless of whether they take antidepressants and those taking antidepressants fall more, regardless of whether they are depressed.
It has long been known that centrally acting medications predispose to falls in older patients. Why should depression cause falls? Older people with depression have an abnormal gait pattern, suggesting a physiological rather than psychological origin of falls. Depression is associated with postural hypotension, which also may predispose to falls.
Depression may also contribute to symptoms of dizziness and fear of falling. Both fear of falling and depression are independently related to stride-to-stride variability, itself a marker of falls risk. Depression is also independently related to fractures. Whatever the reason, depression is a significant and consistent risk factor for falls.
Recently, a cohort study followed over 5000 people for five years, looking at factors that were related to hip fracture. Those taking antidepressants were more than twice as likely to fall and also to have a hip fracture. Surprisingly, only those on SSRIs had an increased risk of falls and fracture.1 SSRIs have been implicated in bone problems in adolescents and those with chronic mental health problems. For older women, the coexistence of osteoporosis, lower limb weakness, depression and use of an SSRI may increase the risk of fracture.
Lorraine has a fall two weeks later while getting up in the night. She spends an hour on the floor, then drags herself to the phone. The ambulance arrives and takes her to hospital, where it is apparent she has a fractured NOF on the L. She has it fixed, and makes a good recovery. You always wonder whether you could have done something for the combination of risks she had. Could this hip fracture have been prevented?
It is also possible falls may lead to depression (reverse causality) by reducing functional status and increasing disability, both factors predicting the development of depression. Whatever the mechanism for the relationship between depression and falls, the presence of one should trigger an inquiry for the other and an offer of appropriate remediation.
It seems physical activity may be a reasonable therapy to offer older people with depression. High level physical activity, either as progressive resistance training or aerobic activity, benefits depression2 although social activity is as efficacious as walking for improving depressive symptoms.3 Activity in the right form can prevent falls as well. A combination of lower limb strengthening, balance retraining and walking is very effective in preventing falls.
Management of depression in older people should include advice about fall prevention, especially if a prescription is being written. The Otago Exercise Programme is funded by ACC and providers can be accessed through the ACC website (www.acc.co.nz/injury-prevention/home-safety/older-adults/otago-exercise-programme/WCMZ003077).
A good update on falls prevention is available on the Goodfellow website (www.goodfellowclub.org) and the depression guidelines are currently being reviewed. Treatments for depression are effective and available, and all risks related to treatments should be considered.
References
1. Richards J et al. Effect of selective serotonin reuptake inhibitors on the risk of fracture. Arch Intern Med 2007;167:188–94.
2. Blumenthal JA et al. Effects of exercise training on older patients with major depression. Archives of Internal Medicine 1999;159(19):2349–56.
3. McNeil JK, LeBlanc EM, Joyner M. The effect of exercise on depressive symptoms in the moderately depressed elderly. Psychology & Aging 1991;6(3):487–8.
4. Robertson MC et al. Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data. Journal of the American Geriatrics Society 2002;50(5):905–11.
Ngaire Kerse is a senior lecturer in general practice and primary healthcare at the University of Auckland.
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