Pharmacological stratification of fall-risk-increasing drugs for prevention of fall-related injuries in older adults: a population-based cohort study

Falls are a major cause of morbidity among older adults. While deprescribing fall-risk-increasing drugs (FRIDs) is recommended for secondary prevention, their high prevalence limits efficient targeting in primary prevention. Stratification by pharmacological FRID subclasses or drugs with fall-risk-increasing adverse reactions (FRIAR-drugs) may improve identification of high-risk patients, yet its added value in routine care is uncertain.

To compare pharmacological FRID classifications with a FRIAR-based framework for predicting fall-related hospitalisations and to identify drug subgroups that differentiate fall-risk among exposed older adults in a primary prevention context.

We conducted a retrospective cohort study including 120 867 adults aged ≥65 years prescribed at least one FRID or FRIAR-drug at baseline. Fall-related hospitalisations in 2019 were identified using International Classification of Diseases, 10th Revision (ICD-10) codes. Multivariate logistic regression evaluated pharmacological FRID (sub)groups and FRIAR-drug classifications, adjusted for established general predictors. Model performance was assessed using internal validation and sensitivity analyses.

During follow-up, 2788 individuals (2.3%) experienced a fall-related hospitalisation. Pharmacological subgroups associated with higher risk included serotonin reuptake inhibitors, older antiepileptics and drugs with moderate anticholinergic properties. In contrast, the FRIAR-drug framework added little prognostic information beyond established FRID classifications. The final model demonstrated moderate discrimination (Area under the curve (AUC) 0.73) with stable predictive performance on internal validation.

Pharmacological stratification of FRIDs allows clinically useful differentiation of fall-risk among exposed older adults, whereas FRIAR-based classification adds limited prognostic value. These findings support more selective prioritisation of medication review in primary-preventive fall strategies, although external validation and evaluation of decision-relevant risk stratification are required.