SSRIs vs Fall Risk in Elderly

Well, it's Sunday night in Stateline, NV and the Niners lost. But the good news is that two talks are done (Care of the Vulnerable Elderly yesterday and Testosterone & Hypogonadism today) and there's only one left to go (Alzheimer's Disease on Tuesday).   Even better is that I learned something yesterday (and today, too).  The topic of selective serotonin reuptake inhibitors (SSRIs) came up during the Self Assessment Module with regards to fall risk.  This was new to many of us as we all believe treating depression and anxiety is important regardless of age.  Moreover, the SSRIs are generally thought to have a better safety profile (aside from risk of serotonin syndrome) than the tricyclic antidepressants (due to anticholinergic side effects and cardiac dysrhythmias at relatively small overdose).

Serendipitiously, I stumbled upon a study published early online just last Thursday in the British Journal of Clinical Pharmacology in which the authors followed 248 institutionalized patients with dementia for 2 years and found a statistically significant association between SSRI dose and fall risk.  As expected, the addition of a sedative-hypnotic only increased the risk of falling.  

Upon looking into this further, I then dug up a prospective cohort study published 5 years ago to the day in Archives of Internal Medicine in which the authors followed over 5,000 community dwelling participants over 50yo for 5yrs and found an increase risk of fractures in those who took SSRIs, everything else being equal.  

Of course, we're all curious as to the possible mechanism of action so I had to look deeper in my USB flashdrive of studies and guess what?  Published six months later in the same journal, authors noted decreased bone mineral density in close to 6,000 men avg 73yo who reported taking SSRIs compared to those taking other antidepressants.  Given that what's good for the gander is good for the goose, in that very same issue, another study of over 2,700 women avg 78yo followed for almost 5yrs noted an increase loss of bone mineral density in those taking SSRIs compared to those taking other antidepressants.  This doesn't necessarily explain the increase in fall risk but it certainly increases my concern for the potential aftermath.

So there you have it.  While association does not imply causation, the evidence certainly is compelling enough for us to reconsider how we're going to treat our depressed elderly, regardless of whether they're demented or not.  Any ideas?

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