Management of use of urinary antimuscarinics and alpha blockers for benign prostatic hyperplasia in older adults at risk of falls: a clinical review

To review the current knowledge and the underlying pathophysiology of fall risk associated with the use of urinary antimuscarinics and alpha-blockers in older adults and help clinicians in (de-)prescribing urinary antimuscarinics and alpha-blockers. Untreated overactive bladder and/or benign prostatic hyperplasia increase fall risk in older adults and so do urinary antimuscarinics and/or alpha-blockers. These drugs contribute to (or cause) falling through dizziness, somnolence, visual impairment, and orthostatic hypotension while they differ in these fall-related side effect profiles. While considering withdrawal of urinary antimuscarinics and alpha-blockers is recommended for older adults under high fall risk, physicians are frequently hesitant to deprescribe these drugs. There are practical resources and algorithms that guide and assist clinicians in deprescribing these drug groups. Comprehension of fall-related side effect profiles of antimuscarinics and alpha-blockers and clinical decision tools such as the STOPPFall withdrawal algorithm help prescribers in attaining rational decisions while (de-)prescribing. We aimed to outline the existing information and the underlying mechanisms of risk of falls associated with the use of urinary antimuscarinics for overactive bladder (OAB) or alpha-blockers for benign prostatic hyperplasia (BPH) in older adults. In addition, we aimed to provide assistance to clinicians in decision-making about (de-)prescribing these drugs in older adults. Based on a literature search in PubMed and Google Scholar, we reviewed the literature, and identified additional relevant articles from reference lists, with an emphasis on the most commonly prescribed drugs in OAB and BPH in older patients. We discussed the use of bladder antimuscarinics and alpha-blockers, their potential side effects related to falls, and the deprescribing of these drugs in older adults. Urinary urgency or incontinence and lower urinary tract symptoms due to untreated OAB and BPH contribute to fall risk. On the other hand, the use of bladder antimuscarinics and alpha-blockers is also related to fall risk. They contribute to (or cause) falling through dizziness, somnolence, visual impairment, and orthostatic hypotension while they differ in their side-effect profiles regarding these problems. Falls are common and can cause a remarkable amount of morbidity and mortality. Thus, preventive measures should be taken to lower the risk. If the clinical condition allows, withdrawal of bladder antimuscarinics and alpha-blockers is recommended in fall-prone older adults. There are practical resources and algorithms that guide and assist clinicians in deprescribing these drug groups. The decision to prescribe or deprescribe these treatments in patients at high risk of falls should be individualized. In addition to explicit tools that are helpful for clinical decision-making in (de-)prescribing these drugs, STOPPFall (a recently developed expert-based decision aid specifically aiming to prevent falls) is present to assist prescribers in attaining decisions.