Pain and pain medications are risk factors for hip fracture falls
One of the goals of surgery is to reduce the need for painkillers because of the long-term effects these medications can have on people. During the pandemic, when access to medical care and orthopedic surgery were compromised, many people found themselves being prescribed and taking more painkillers and anti-inflammatories to manage their chronic pain. As elective surgeries were push back and delayed, more pills were given.
Painkillers and anti-inflammatories medications come with many well known and well documented side effects. Among these side effects is the increased risk that the person will take a fall significant enough to fracture a hip.
Pain and joint instability, especially in the hips, knee, low back and ankles, where weight bearing is greatest can increase your fall risk. It is of course a great irony that when you consider that the very medications to prevent pain can cause you to fall.
Let’s note that pain doctors have long suggested that pain was a substantial risk factors for falls. A 2014 study wrote (1): “Falls-related outcomes were substantially more common in older adults with pain than in those without. Accordingly, pain management strategies should be developed and evaluated for falls prevention.” Other research therefore made the connection that if you could reduce pain you could reduce the risk of falls and a fractured hip. For some doctors this took them down the path of pain management with opioids and narcotic medications. Other doctors, like myself try to solve the same problem with regenerative medicine.
An October 2022 paper (2) cited this study and suggested on its own: “pain was associated with subsequent increased falls risk in community-dwelling adults. Greater intensity of pain was associated with an increased falls risk . . . this association was more pronounced in middle-aged adults. Multisite pain was associated with an increased falls risk compared to pain in one site only. ”
Falls amongst older people are common; however, around 40% of falls could be preventable
In November 2020, (3) researchers in the United Kingdom noted that while “Falls amongst older people are common; however, around 40% of falls could be preventable.” How are they preventable? To this research team the answer was to reduce a patient’s medication usage. The research team continued: “Medications are known to increase the risk of falls in older adults. The debate about reducing the number of prescribed medications remains controversial, and more evidence is needed to understand the relationship between polypharmacy (medication usage) and fall-related hospital admissions.”
The findings here suggest that the more medications one takes, the greater the risk of fall. In this study of over 6,000 patients, 15% of those taking excessive (some say unnecessary medications) wound up in the hospital from a fall. The conclusion the researchers reached was: “The risk of hospitalization due to a fall increased with polypharmacy. It is suggested that prescriptions in older people should be revised on a regular basis, and that the number of medications prescribed be kept to a minimum, in order to reduce the risk of fall-related hospital admissions.”
Despite the risks, programs to prevent falls do not overwhelming prevent hip fractures.
An August 2022 study (4) tried to give doctors the typical characteristics of fallers who later sustain a hip fracture and provide a commentary on the success or lack of success of programs designed to help these people NOT to fall. Here is what they wrote: “Fall prevention programs have shown inconclusive results concerning hip fracture reduction. We found that fallers with poor health, low societal participation, and use of psychotropics/painkillers had a threefold to fivefold increased hip fracture risk compared to non-fallers without these risk factors. This may help target fall prevention towards high-risk individuals.
- More women (32.4%) than men (27.7%) reported one or more falls during the previous year, and 17.9% of women and 8.9% of men suffered a hip fracture during average 11.6 years of follow-up.
Fall risk increasing drugs (FRID) – an understudied topic
A December 2021 paper (5) also warned of a seemingly unnoticed problem of fall risks and over prescribing of medication. Here is what these researchers wrote: “The effect of persistent polypharmacy (i.e. using multiple medications over a long period) on fall injuries is understudied, particularly for outpatient (at home) injuries. . . Among 1764 participants, 636 (36%) had persistent polypharmacy over the follow-up period, and 1128 (64%) did not. Fall injury incidence was 38 per 1000 person-years. Persistent polypharmacy increased fall injury risk . Persistent polypharmacy with Fall risk increasing drugs (FRID) use was associated with a 48% increase in fall injury risk vs. those who had non-persistent polypharmacy without FRID use . . . Clinicians may need to consider medication management for FRID and other fall prevention strategies in community-dwelling older adults with persistent polypharmacy to reduce fall injury risk.”
Poorer balance, physical function and strength and reported increased concern about falls
A March 2020 study (6) looked at 70 year old and older patients who suffered with knee pain. Compared to a similar group with no knee pain, these patients took more medications and had more medical conditions. In addition, the people with knee pain had poorer balance, physical function and strength and reported increased concern about falls. Sixty one participants (20%) reported more than two falls, with the people in the knee pain group twice as likely to experience multiple falls over the 12 month follow up. The researchers concluded their paper by suggesting: “This study has identified several medical, medication, psychological, sensorimotor, balance and mobility factors to be associated with knee pain, and found the presence of knee pain doubles the risk of multiple falls in older community living people. Alleviating knee pain, as well as addressing associated risk factors may assist in preventing falls in older people with knee pain.”
Medications for bladder problems and depression can increase the risk of falls
A May 2021 study (7) looked at anticholinergic medication (for bladder problems and depression) as a potential risk for causing falls. The research team writes: anticholinergic medication “may increase the risk of falls. These medications are used to treat common health issues including depression and bladder problems. Anticholinergic burden is the term used to describe the total effects from taking these medications. Some people may use more than one of these medications. This would increase their anticholinergic burden.”
“It is possible that reducing the use of these medications could reduce the risk of falls. . . We learned that people who are moderate to high users of these medications (often people who will use more than one of these medications) had a higher risk of falling. It was less clear if people who have a lower burden (often people who only use one of these medications) had an increased risk of falling. . . .These findings suggest that we should reduce use of these medications. This could reduce the number falls and improve the well-being of older people.”
Our treatment options
Over the years we have seen a lot of people with chronic pain in their hips, knees and ankles with the accompanying joint instability. They have had many treatments and for many they are now “pain-managed” with medications. We work with these patients to help alleviate their pain and restore function so they can safely and responsibly reduce or eliminate their medication burden.
Our treatment options to help strengthen joints and reduce or eliminate pain include:
- PRP treatments which involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration. PRP utilizes the blood’s platelets and their healing and tissue repair factors.
- A demonstration of the treatment is shown in the video below.
References
1 Patel KV, Phelan EA, Leveille SG, Lamb SE, Missikpode C, Wallace RB, Guralnik JM, Turk DC. High prevalence of falls, fear of falling, and impaired balance in older adults with pain in the United States: findings from the 2011 National Health and Aging Trends Study. Journal of the American Geriatrics Society. 2014 Oct;62(10):1844-52.
2 Ogliari G, Ryg J, Andersen-Ranberg K, Scheel-Hincke LL, Collins JT, Cowley A, Di Lorito C, Howe L, Robinson KR, Booth V, Walsh DA. Association of pain and risk of falls in community-dwelling adults: a prospective study in the Survey of Health, Ageing and Retirement in Europe (SHARE). European geriatric medicine. 2022 Dec;13(6):1441-54.
3 Zaninotto P, Huang YT, Di Gessa G, Abell J, Lassale C, Steptoe A. Polypharmacy is a risk factor for hospital admission due to a fall: evidence from the English Longitudinal Study of Ageing. BMC public health. 2020 Dec;20(1):1-7.
4 Søgaard AJ, Aga R, Holvik K, Meyer HE. Characteristics of fallers who later sustain a hip fracture: a NOREPOS study. Osteoporosis international. 2022 Aug 4:1-2.
5 Xue L, Boudreau RM, Donohue JM, Zgibor JC, Marcum ZA, Costacou T, Newman AB, Waters TM, Strotmeyer ES. Persistent polypharmacy and fall injury risk: the Health, Aging and Body Composition Study. BMC geriatrics. 2021 Dec;21(1):1-0.
6 Hicks C, Levinger P, Menant JC, Lord SR, Sachdev PS, Brodaty H, Sturnieks DL. Reduced strength, poor balance and concern about falls mediate the relationship between knee pain and fall risk in older people. BMC Geriatr. 2020 Mar 6;20(1):94. doi: 10.1186/s12877-020-1487-2. PMID: 32138672; PMCID: PMC7059317.
7 Stewart C, Taylor-Rowan M, Soiza RL, Quinn TJ, Loke YK, Myint PK. Anticholinergic burden measures and older people’s falls risk: A systematic prognostic review. Therapeutic advances in drug safety. 2021 May;12:20420986211016645.