This study was a chart review of geriatric fall patients in 2013–14, 2018–19, and 2023.

The prevalence of gabapentinoid prescriptions increased more than four-fold from 2013–14 to 2023, alongside a marked decline in opioid prescriptions. A remarkable variability was found in the indications for which gabapentinoids had been prescribed, with a clear trend toward prescribing gabapentinoids for indications not supported by national guidelines. A slight, nonsignificant increase in concurrent gabapentinoid and opioid use was found.

The use of gabapentinoids has received increasing scientific interest in recent years, and a rising use has been documented in several countries, including the UK, the USA, and Australia [7, 27, 28]. The findings of the current study support studies of the general adult population while highlighting that geriatric patients are particularly vulnerable. Data on dispensed prescriptions from the Danish registry shows that there has been a three-fold increase in total dispensed gabapentinoid prescriptions, with the highest prevalence in the oldest individuals: for those aged > 80, the proportion increased from 3% in 2013–14 to 10% in 2023 [16]. The current study found a significant increase in gabapentinoid prescriptions from 2013–14 to 2023, with an estimated prevalence of 15% [95% CI 10.1–20.3] in 2023. While it may be unsurprising that gabapentinoid use among frail geriatric patients is higher than among the general population of older individuals, it is nonetheless worrisome, given the increased risk of falls. The reasons for the growing use of gabapentinoids are not entirely known. It has been proposed that the increasing trend is a consequence of the opioid crisis, where several countries have implemented restrictions on opioid use. In addition, paracetamol is often ineffective for treating moderate-to-severe chronic pain, and NSAIDs are contraindicated in many patient groups, including older adults [4, 9].

Considering the rise in gabapentinoid usage found in this study, it is important to highlight that the prevalence of pain in the study population likewise increased from 52.8% in 2013–14 to 73.2% in 2018–19 and to 77.9% in 2023. Several reasons for this increase in reported pain can be postulated, of which three are described in the following: first, it could signify that the prevalence of pain in the general population is increasing owing to various potential factors, such as a rise in obesity, depression, and chronic conditions [29]—which is also supported by the substantial increase in paracetamol prescriptions seen in the current study. A second reason could be a shift in referral patterns, which the decrease in frailty among patients in this study may point towards. Third, changes in documentation practices and an increased focus on documenting pain cannot be entirely ruled out and may have contributed to the increased prevalence in our data. However, principles of CGA remained the same, and the same consultant handled visitation throughout the period, making it more likely that changes in pain prevalence reflect actual changes in the background population or in the population of patients referred to the geriatric falls clinic.

Despite stable age, frailty in the study population has decreased over time, likely reflecting advances in chronic disease management, preventive care, and improved living conditions with greater access to assistive devices.

Opioid consumption drastically decreased over time from 29.2% in 2013–14 to 11.9 % in 2023. This is likely due to regulations, guidelines, and increased awareness of the harms of prescribing opioids for chronic pain, particularly in the older population [30]. It can be speculated that the decrease in opioid usage over the period might have led to increased pain among patients and, perhaps even more likely, to an increase in nonopioid pharmacological alternatives for managing chronic pain. Therefore, while the opioid-reduction initiatives have been effective in reducing opioid use, there have not concurrently been sufficient initiatives for pain relief, which are equally, if not more, important [31].

In this study, 68 patients received gabapentinoids. Of the 65 patients who were prescribed gabapentinoids for pain, 42 (62%) had it prescribed for conditions for which their use was not supported by national guidelines, 18 (26%) for vaguely supported indications, and only 5 (7%) for indications that were clearly supported in guidelines, these being postherpetic neuralgia and painful diabetic neuropathy [12, 13, 22]. Among those receiving gabapentinoids for conditions not supported by guidelines, most had back pain or other types of nociceptive pain, where clinical trials do not support the pain-relieving effect [22, 23]. Nearly one in four (n = 15) patients received gabapentinoids for radiculopathy, which guidelines vaguely “recommend in certain situations” but which, nonetheless, is inconsistent with current evidence, which is inconclusive at best [32,33,34]. Three patients received pregabalin for fibromyalgia, which there is some evidence for in a minority of patients receiving daily doses ≥ 300 mg, and Danish guidelines state gabapentinoids can be trialed in these patients unless they have an increased risk of falling [23, 35]. Interestingly, all three patients concurrently received opioids, and two received pregabalin at suboptimal dosages, which was discontinued at the falls clinic [36].

Our findings are in line with similar reports in other countries, where gabapentinoids have been increasingly used off-label for conditions with inconsistent evidence, such as nonspecific pain syndromes and nociceptive pains, with and without neuropathic components [9, 36].

Studies have demonstrated a dosage-related link between gabapentinoids and adverse events such as dizziness, which is generally reported three times more when compared with placebo, and somnolence, which is also three-fold more prevalent in patients receiving these drugs [12, 13].

As with any centrally acting drug, adverse events are likely, especially in older people, warranting careful consideration when given to geriatric patients at risk of falls and the well-established negative consequences hereof [14]. In an Australian study (n = 28,293) gabapentinoid use was found to be associated with increased odds of hip fractures, especially among frail patients and those with impaired kidney function [37].

While some researchers claim addictive properties and a misuse potential of gabapentinoids, the research is mostly inconclusive [38]. However, misuse has repeatedly been shown to be disproportionately large in individuals with current or previous opioid use disorder, further underscoring the need for being mindful of the uncritical substitution of opioids with gabapentinoids [38].

A strength of this study is that assessments were all made by geriatric physicians and physiotherapists at the same clinic following the same assessment patterns. The same consultant oversaw the clinic and handled visits during the study period. Medication usage was determined on the basis of medical status, reported mainly by geriatric physicians, instead of dispensed prescriptions, which might provide a more accurate estimation of actual medication consumption. In addition, data extracted from the charts to assess indications for gabapentinoid use was carried out collaboratively by H.A. and J.S., further minimizing bias. For other data points, inter-rater agreement was tested, and consistency was observed in data extraction from charts.

Still, this study has some limitations—firstly, as a retrospective cross-sectional chart review, this study inherently cannot establish causality. Moreover, differences in referral practices to the falls clinic could explain a relatively large proportion of excluded patients in earlier years, mainly in 2018–19. In 2023, a notable number of patients were excluded owing to absent medication status in charts, likely due to changes in documentation policy. However, there were no important differences between excluded and included patients. The generalizability of this study is primarily applicable to older individuals with a high burden of comorbidities and frailty, and may not extend to younger, healthier populations or those from different geographic or socio-economic backgrounds. Further, while there are some indications in the literature that our results may point to a global trend, they do come from one fall clinic in Denmark and warrant further research from other countries to support our findings.

This study underscores the need for increased focus on the prescribing of gabapentinoids for off-label indications in geriatric populations. In addition, clinicians should be aware that, most often, the best treatment of chronic pain is not one that seeks to eliminate it but rather to control it adequately [9, 14, 31]. While analgesics hold a place in the treatment of chronic pain, it is a complex endeavour, and pharmacological options should not stand alone.

Future prospective studies need to evaluate the long-term risks and benefits of gabapentinoid use in frail geriatric populations. In addition, future research should explore strategies for safely reducing or discontinuing gabapentinoids, particularly when their clinical benefit is marginal or uncertain, and follow up on the clinical consequences of deprescribing.