Regular Research Article
The Complex Interplay of Depression and Falls in Older Adults: A Clinical Review

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Depression and falls have a significant bidirectional relationship. Excessive fear of falling, which is frequently associated with depression, also increases the risk of falls. Both depression and fear of falling are associated with impairment of gait and balance, an association that is mediated through cognitive, sensory, and motor pathways. The management of depression in fall-prone individuals is challenging, since antidepressant medications can increase the risk of falls, selective serotonin reuptake inhibitors may increase the risk of fragility fractures, and data are lacking about the effect of fall rehabilitation programs on clinically significant depression. Based on the current state of knowledge, exercise (particularly Tai Chi) and cognitive–behavioral therapy should be considered for the first-line treatment of mild depression in older fallers. Antidepressant medications are indicated to treat moderate to severe depression in fall-prone individuals, but with appropriate precautions including low starting dose and slow dose titration, use of psychotropic monotherapy whenever possible, and monitoring for orthostatic hypotension and hyponatremia. To date, there have been no recommendations for osteoporosis monitoring and treatment in individuals prescribed antidepressant medications, beyond the usual clinical guidelines. However, treatment of the older depressed person who is at risk of falls provides the opportunity to inquire about his or her adherence with osteoporosis and fracture prevention guidelines.

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

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