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Clinician Article

Antipsychotic Drugs and Risk of Hip Fracture in People Aged 60 and Older in Norway.



  • Bakken MS
  • Schjott J
  • Engeland A
  • Engesaeter LB
  • Ruths S
J Am Geriatr Soc. 2016 Jun;64(6):1203-9. doi: 10.1111/jgs.14162. (Original)
PMID: 27321599
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Disciplines
  • Psychiatry
    Relevance - 6/7
    Newsworthiness - 7/7
  • Family Medicine (FM)/General Practice (GP)
    Relevance - 6/7
    Newsworthiness - 6/7
  • General Internal Medicine-Primary Care(US)
    Relevance - 6/7
    Newsworthiness - 6/7
  • Geriatrics
    Relevance - 6/7
    Newsworthiness - 4/7

Abstract

OBJECTIVES: To examine associations between exposure to various subgroups of antipsychotic drugs and risk of hip fracture in older adults.

DESIGN: Nationwide cohort study.

SETTING: Norway, 2005-2010.

PARTICIPANTS: Everyone living in Norway born before 1945 (N = 906,422).

MEASUREMENTS: Information was obtained on all prescriptions of antipsychotic drugs dispensed from 2004 to 2010 (Norwegian Prescription Database) and data on all primary hip fractures from 2005 to 2010 (Norwegian Hip Fracture Registry). Incidence rates of hip fracture during person-time exposed and unexposed to antipsychotic drugs were compared by calculating the standardized incidence ratio (SIR).

RESULTS: Thirty-nine thousand nine hundred thirty-eight (4.4%) participants experienced a primary hip fracture. Greater risk of hip fracture was associated with exposure to any antipsychotic (SIR = 2.1, 95% confidence interval (CI) = 1.9-2.1), first-generation antipsychotics (SIR = 2.0, 95% CI = 1.8-2.2), second-generation antipsychotics (SIR = 2.2, 95% CI = 1.9-2.4), prolactin-sparing antipsychotics (SIR = 2.4, 95% CI = 1.8-3.1) and prolactin-elevating antipsychotics (SIR = 2.0, 95% CI = 1.9-2.2).

CONCLUSION: In people aged 60 and older in Norway, those who took an antipsychotic drug had twice the risk of sustaining a hip fracture during exposure than during nonexposure. Although confounding by indication, comorbidity, or other drugs used cannot be excluded, this association is relevant for clinical practice because hip fracture and antipsychotic drug use are prevalent in vulnerable older individuals. Clinical studies examining mechanisms or causality of the observed association between antipsychotic drug use and excess risk of hip fracture are needed.


Clinical Comments

Family Medicine (FM)/General Practice (GP)

While this is only an association, the division of results into antipsychotic class is useful.

General Internal Medicine-Primary Care(US)

These are interesting data and it's an association that needs further exploration. I imagine primary care providers will be interested and want to see further research on this question.

General Internal Medicine-Primary Care(US)

It's well known that psychotropic drugs are associated with falls. Risk is probably overstated in this study; there is incomplete adjustment for confounders.

Geriatrics

It is well-known that antipsychotic treatment is associated with falls, as well as with strokes and death for any cause. This study does not add more to our knowledge. Avoiding chemical restraint is what the new guidelines for agitation in dementia suggest; although, there is no evidence from well-design clinical trials that these recommendation led to a reduction of injuries. Instead it seems logical that acathisia if not treated put patients at risk of falling. This is the trade-off.

Geriatrics

This is a large study with interesting results but must be interpreted with caution as there are confounders that are impossible to eliminate or fully adjust for. Causal effects cannot be assumed and further prospective studies are required.

Psychiatry

As a practicing geriatric psychiatrist, I was unaware of this finding: antipsychotic meds are associated with a two-fold rate of hip fracture in people over the age of 60. The authors are careful to point out that this is only an epidemiological study, and they did not control for a myriad of confounding factors - but still - this might give us more pause before we prescribe antipsychotics for our elderly patients. Of course, we often have no good alternative.

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