Intended for healthcare professionals

Clinical Review State of the Art Review

Prevention of falls in older people living in the community

BMJ 2016; 353 doi: (Published 28 April 2016) Cite this as: BMJ 2016;353:i1419

Pain and pain killers: the falls tradeoff.

In their insightful review about falls prevention in community dwelling older people, Vieira and colleagues [1] list pain (such as lower limb pain or foot pain) as a risk factor for falls. In this regard, the association between pain and falls is well known and backed by data from large cohorts of patients [2].

Drugs (and other treatments) can reduce pain and thus pain appears a “modifiable risk factor for falls” [1]. In this scenario, the reduction of pain not only improves older people's quality of life, but also reduces their risk of falls.

However, the efficacy of acetaminophen, i.e. the common first-line therapy for chronic pain, has been recently questioned [3] and oral non-steroidal anti-inflammatory drugs (NSAIDs) are not recommended for long-term use in the elderly [4]. Opioid analgesics are effective for chronic pain [5], but opioids are a falls risk factor per se [6], possibly because of their sedative effect. Moreover, opioids are associated with some other important adverse events in elderly patients [7]. Finally, adding (at least) a new pill for pain control increases the total number of drugs (at least) by one and the use of more than three drugs is a risk factor for falls by itself [1].

I feel it is important to emphasise one major point raised by Vieira and colleagues. The multifactorial assessment and intervention for fall prevention in older people should also cover the “systematic assessment and management of pain” [1]. Pain assessment and management is taken into consideration only by a minority of guidelines for falls prevention among older people, as effectively shown by Figure 2 of the review by Vieira et al.. Research is needed to find the best possible compromise between oral drugs for pain and fall risk in older people. Effectiveness in fall prevention of topical drugs and non-pharmacological therapies with recognised efficacy in pain control (such as topical NSAIDs [8] and strength training [9] in osteoarthritis) remains to be clarified as well.

[1] Vieira E, Palmer R, Chaves P. Prevention of falls in older people living in the community. BMJ 2016;:i1419. doi:10.1136/bmj.i1419
[2] Leveille S. Chronic Musculoskeletal Pain and the Occurrence of Falls in an Older Population. JAMA 2009;302:2214. doi:10.1001/jama.2009.1738
[3] Machado G, Maher C, Ferreira P et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ 2015;350:h1225-h1225. doi:10.1136/bmj.h1225
[4] Makris U, Abrams R, Gurland B et al. Management of Persistent Pain in the Older Patient. JAMA 2014;312:825. doi:10.1001/jama.2014.9405
[5] Pharmacological Management of Persistent Pain in Older Persons. Journal of the American Geriatrics Society 2009;57:1331-1346. doi:10.1111/j.1532-5415.2009.02376.x
[6] Söderberg K, Laflamme L, Möller J. Newly Initiated Opioid Treatment and the Risk of Fall-Related Injuries. CNS Drugs 2013;27:155-161. doi:10.1007/s40263-013-0038-1
[7] Jena A, Goldman D, Weaver L et al. Opioid prescribing by multiple providers in Medicare: retrospective observational study of insurance claims. BMJ 2014;348:g1393-g1393. doi:10.1136/bmj.g1393
[8] Derry S, Conaghan P, Da Silva J et al. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database of Systematic Reviews Published Online First: 2016. doi:10.1002/14651858.cd007400.pub3
[9] Uthman O, van der Windt D, Jordan J et al. Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis. BMJ 2013;347:f5555-f5555. doi:10.1136/bmj.f5555

Competing interests: No competing interests

04 May 2016
Antonio Caronni
MD, PhD, specialist in Physical Medicine and Rehabilitation
Department of Neurorehabilitation Sciences, Casa di Cura del Policlinico
Via Dezza 48, 20144 Milan, Italy.