Regular Research ArticleThe Complex Interplay of Depression and Falls in Older Adults: A Clinical Review
Section snippets
Depression and Falls
Depression and falls are frequently associated. A recent meta-analysis summarized the findings of 17 prospective studies and found an odds ratio for the association of depression with falls of 1.63 (95% confidence interval [CI]: 1.36–1.94).6 The relationship between depression and falls is complex and bidirectional (Figure 1). Depression is an independent risk factor for falls. In one prospective study, there were four determinants of recurrent falls: postural sway, history of falls, handgrip
Fear of Falling
Fear and anxiety is another significant cognitive–affective response to falling. Fear of falling can be an expected and adaptive response to having experienced a fall. However, fear of falling can be excessive and disabling, to the point where an individual may be agoraphobic. It is not always easy to distinguish between an adaptive and an unhealthy fear of falling. For example, in a study of hospitalized fallers, only 1 of 48 individuals with moderate to severe fear of falling felt that this
Antidepressants and Falls
Antidepressants are a commonly prescribed medication in older adults, in 9% of community-dwelling seniors to as high as 31% of nursing home residents.46 Their use has been associated with falls. A recent meta-analysis found that the odds ratio of falls with antidepressants was 1.68 (1.47–1.91),47 similar to the risk associated with benzodiazepines and antipsychotics. These data are based on pharmacoepidemiologic studies, which are subject to “confounding by indication,” that is confounding by
Depression, Antidepressants, and Fractures
SSRI antidepressants have been found to be associated with fragility fractures, more so than other classes of psychotropic medications.54, 55 This association was first observed in a series of case–control studies using large administrative databases54, 55, 56 but has since been replicated with prospective cohort studies.57, 58 In a multivariate analysis, controlling for such factors as depressive symptoms, falls history, visual and cognitive impairment, comorbidities, postural hypotension,
Depression, Fear of Falling, Falls Prevention, and Exercise
Preventative programs for falls are now widespread, often incorporating some or all of the components of falls risk assessment, education, and exercise to improve balance and strength. A recent meta-analysis reported that fall-prevention programs are effective in reducing falls by an average of 14% over at least 5 months of observation.75 An earlier Cochrane Review, however, found significant heterogeneity in the outcomes of falls-prevention interventions, with some randomized controlled trials
Depression and Falls: Clinical Implications
An overall assessment for falls risk is important when starting psychotropic medication in fall-prone individuals. This would include an assessment of other falls promoting medications, checking for drug interactions, observing gait and tone, and inquiring about falls history. Given that most falls occur early in treatment and may potentially be dose-related, SSRI medications should be started at a low dose and increased slowly in older adults to minimize their effect on falls. Cognitive
Future Directions
As this review indicates, research evidence suggests that both depression and antidepressant medication are associated with falls and fractures. Moreover, while exercise and cognitive–behavioral therapy have benefit in treating mild-moderate depression in the general older adult population, there are currently no data pertaining to the efficacy and feasibility of these interventions in persons who both are at high risk of falls and are clinically depressed. Thus, clinicians currently find
References (84)
- et al.
Major and minor depression in later life: a study of prevalence and risk factors
J Affect Disord
(1995) - et al.
A risk model for the prediction of recurrent falls in community-dwelling elderly: a prospective cohort study
J Clin Epidemiol
(2002) - et al.
A meta-analysis of depression severity and cognitive function
J Affect Disord
(2009) - et al.
Gait variability and fall risk in community-living older adults: a 1-year prospective study
Arch Phys Med Rehabil
(2001) - et al.
Risk factors for anxiety and depression in the elderly: a review
J Affect Disord
(2008) - et al.
Affective correlates of fear of falling in elderly persons
Am J Geriatr Psychiatry
(2005) - et al.
Feelings of anxiety and symptoms of depression in community-living older persons who avoid activity for fear of falling
Am J Geriatr Psychiatry
(2008) - et al.
What is the relationship between fear of falling and gait in well-functioning older persons aged 65 to 70 years?
Arch Phys Med Rehabil
(2010) - et al.
A structural equation model relating impaired sensorimotor function, fear of falling and gait patterns in older people
Gait Posture
(2007) - et al.
The relationship between fear of falling and human postural control
Gait Posture
(2009)
Prevalence and predictors of antidepressant prescribing in nursing home residents in the United States
Am J Geriatr Pharmacother
Comparative effects of sertraline and nortriptyline on body sway in older depressed patients
Am J Geriatr Psychiatry
Effects of nortriptyline and paroxetine on postural sway in depressed elderly patients
Am J Geriatr Psychiatry
Use of selective serotonin-reuptake inhibitors of tricyclic antidepressants and risk of hip fractures in elderly people
Lancet
Effects of selective serotonin reuptake inhibitors on bone health in adults: time for recommendations about screening, prevention and management?
Bone
Major depression is a risk factor for low bone mineral density: a meta-analysis
Biol Psychiatry
Treatment of a major depression episode suppresses markers of bone turnover in premenopausal women
J Psychiatr Res
Mood improvement in elderly women after in-hospital physical rehabilitation
Arch Phys Med Rehabil
Association of serotonin-1A and 2A receptor promoter polymorphisms with depressive symptoms and functional recovery in elderly persons after hip fracture
J Affect Disord
Association of the serotonin transporter gene-linked polymorphic region (5-HTTLPR) genotype with depression in elderly persons after hip fracture
Am J Geriatr Psychiatry
Effectiveness of intervention programs in preventing falls: a systematic review of recent 10 years and meta-analysis
J Am Med Dir Assoc
Risk factors for falls among elderly persons living in the community
N Engl J Med
Activity restriction induced by fear of falling and objective and subjective measures of physical function: a prospective cohort study
J Am Geriatr Soc
Fear of falling and postural performance in the elderly
J Gerontol
Anxiety and depression in later life: co-occurrence and communality of risk factors
Am J Psychiatry
Risk factors for falls in community-dwelling older people: a systematic review and metaanalysis
Epidemiology
Actigraphy-measured sleep characteristics and risk of falls in older women
Arch Intern Med
Nutritional status in relation to balance and falls in the elderly: a preliminary look at serum folate
Ann Nutr Metab
D for depression: any role for vitamin D?
Acta Psychiatr Scand
The role of executive function and attention in gait
Mov Disord
Dual-task decrements in gait: contributing factors among healthy older adults
J Gerontol A Biol Sci Med Sci
The impact of depression on dual tasking among patients with high fall risk
J Geriatr Psychiatry Neurol
Embodiment of sadness and depression—gait patterns associated with dysphoric mood
Psychosom Med
Gait unsteadiness and fall risk in two affective disorders: a preliminary study
BMC Psychiatry
Gait changes in older adults: predictors of falls or indicators of fear
J Am Geriatr Soc
Physiological and cognitive mediators for the association between self-reported depressed mood and impaired choice stepping reaction time in older people
J Gerontol A Biol Sci Med Sci
Depression and falls among community dwelling elderly people: a search for common risk factors
J Epidemiol Community Health
A novel aging phenotype of slow gait, impaired executive function, and depressive symptoms: relationship to blood pressure and other cardiovascular risks
J Gerontol A Biol Sci Med Sci
Are recurrent fallers depressed?
J Am Geriatr Soc
Psychological well-being is an independent predictor of falling in an 8-year follow-up of older adults
J Gerontol B Psychol Sci Soc Sci
Repeat falls and the recovery of social participation in the year post–hip fracture
Age Ageing
Determinants of disparities between perceived and physiological risk of falling among elderly people: Cohort study
BMJ
Cited by (184)
Fear of falling and common symptoms of multiple sclerosis: Physical function, cognition, fatigue, depression, and sleep – A systematic review
2024, Multiple Sclerosis and Related DisordersPhysical strength and mental health mediate the association between pain and falls (recurrent and/or injurious) among community-dwelling older adults in Singapore
2023, Archives of Gerontology and GeriatricsDiuretic use and risk of falls in older women with urinary incontinence
2023, Geriatric Nursing