NFPA Journal

BY JESSE ROMAN 


For years, health and safety experts have believed that prescription medication and drug use among seniors is a significant factor in falls, and possibly fires. But research on the issue has been scattered, making it difficult to draw conclusions or to formulate and deliver appropriate safety messages. As a result, the topic has been absent from efforts like Remembering When™, an NFPA educational program aimed at helping seniors reduce their risk of experiencing a fire or fall.

Recently, though, calls by the safety community to re-examine the issue led NFPA to ask its research affiliate, the Fire Protection Research Foundation, to investigate. Last year, the Foundation contracted with FireTox, a Maryland-based research firm, to collect and review the relevant academic studies and catalog the insights that emerged. The resulting report, “Review of Impact of Medications on Older Adult Fall and Fire Risk,” was published last November and leaves little doubt as to the role that medications can play in causing falls among seniors, said Jamie McAllister, the technical director at FireTox and the lead author of the report.

“There are a number of different medications identified in the various sources that we reviewed that were found to increase the risk of falls and fall injuries for older adults,” McAllister said. “In addition, removing or replacing a certain medication, or maybe even just reducing the dose of the medication in somebody’s treatment regimen, can actually prevent the occurrence of a fall.”

One outcome of the findings is that medication use is now a focus of Steps to Safety™, the new older-adult falls and fire prevention program designed by NFPA. Steps to Safety builds on the messaging of Remembering When with a more flexible digital delivery that features video, social media, and other engagement tools. The new program is scheduled to launch this summer.

According to studies included in the FireTox report, older adults taking antidepressants, benzodiazepines (such as Xanax and Valium), opioids, and insomnia medications seem to exhibit an increased risk of cognitive impairments, falls, and fractures. Taking these drugs in combination can further increase the risk. Conversely, removing drugs may have a beneficial effect. In one study, researchers weaned fall-prone patients off psychotropic drugs and found that it decreased the occurrence of falls by 66 percent.

While on the surface the findings seem fairly intuitive—it’s hardly surprising that an older adult struggling with balance will struggle more under the influence of a psychoactive chemical—digging in further reveals some startling details. Older adults, it seems, are taking pharmaceuticals in fantastic quantities and in combinations that could be dangerous.

According to the research reviewed in the report, 66 percent of adults 65 and older use three or more prescription medications, and approximately 42 percent use at least five or more. Perhaps because of this intake, one study found that 25 percent of seniors have had one or more drug-drug interactions, meaning they’ve taken two or more drugs that have “unfavorable results when taken together,” McAllister said. Approximately 15 percent of older adults—more than 8 million people in US—are at risk for potential “major drug-drug interactions,” according to one study detailed in the Foundation report.

What’s more, as much as 35 percent of the older adult population drinks while taking medications that are known to interact negatively with alcohol. Taking certain drugs in combination or with alcohol can “create this additive or synergistic effect,” McAllister said. Often it can enhance or otherwise impact the absorption, distribution, metabolism or even the physiological effect of the drug, and possibly make a patient who is already unsteady on their feet even more so.

When it comes to medications and fire risk, however, the available research is thinner and less conclusive. “We have a much smaller pool of studies that have been conducted, and they’ve largely focused on how medications impact awakening to a smoke alarm,” McAllister said. “But little research has been done on how drugs affect us when we are awake, and if they might affect one’s ability to perceive a fire hazard and respond accordingly.”

Although the findings were inconclusive about how drugs impact fire risk, there were several studies included in the Foundation report that strongly suggest there could be a correlation, if not a direct causation. Of particular concern are drugs that induce a deep sleep, such as benzodiazepines, sleeping aids, and alcohol. In one study from 1997, researchers looked at a series of tests on people who had been given drugs and then assessed on how easily they were awakened by a smoke alarm. In one such experiment from the 1970s, half of the participants who were given benzodiazepines failed to wake to the first alarm signal. The researchers concluded in the 1997 study that higher amounts of alcohol or drugs “will cause longer stages of deep sleep that may leave the person in a comatose state.”

More broadly, studies have revealed that drugs and alcohol show up with some frequency in toxicology reports of people who have died in a fire, regardless of age. In a 2019 study from Ireland, researchers found that 76 percent of fire victims in the country aged 60 and over had alcohol and/or drugs in their systems at the time of death. Another study from Australia found that people who died in fires over a 10-year period, and who had tested positive for drugs, had an average of 1.5 psychotropic drugs in their systems at the time of death. One study found that 74 percent of fire victims aged 65 and over were smokers and 64 percent were considered “problem drinkers.”

While the details show convincingly that medical and recreational drugs do have an influence on fall risk—and at the very least probably don’t help when it comes to fires—there appears to be little, if any, targeted outreach to older adults on the issue. A survey of existing fall and fire prevention programs conducted by FireTox found that “specific information on medication uses or medication types and its association with fall risks is not addressed” in any of the fall programs. None of the fire prevention programs reviewed included information for seniors on medication use and fire risk.

Some of that likely has to do with a lack of understanding of the extent of the problem among educators, said Ashby Anderson, a sergeant with the fire prevention bureau at the Louisville (Kentucky) Fire Department. But she believes it also stems from a reluctance to overstep or broach topics that might be considered off-limits or too personal.

“I hate to say it, but I do feel that there's a real aversion to certain safety messaging that could be considered too direct or too personal,” Anderson said. “And so public educators are often reluctant to bring up certain subjects like drinking habits or medications, but I would like to get to the point where we are encouraging a more open and authentic dialogue around the real-world challenges that our vulnerable populations face. I think having more direct conversations where everything is on the table will translate into more meaningful outcomes.” 

The messaging being developed for the Steps to Safety program will not involve chastising people about their habits or medication regimen, according to Andrea Vastis, director of public education at NFPA. Instead, the focus will be on making sure older adults are aware of the known risks of medications, falls, and fires. They will also be encouraged to keep a current list of the medications they’re taking and review that list frequently with a medical professional.

“We’re not looking for our fire department and our elder care services people to pretend they’re pharmacists or doctors, but there are some key messages that come out of this,” Vastis said. “We want people to stay on their medications, we want people to adhere to their regimen, but we also want them to be aware of things that could happen on the other side of it.”