If so, do you know if any of your medications might be increasing your risk for falls?
In its Stay Independent brochure, the Centers for Disease Control (CDC) recommends older adults do the following four things to prevent falls:
- Begin an exercise program to improve leg strength and balance.
- Ask your doctor or pharmacist to review your medicines.
- Get annual eye check-ups and update your glasses.
- Make your home safer.
In this article, we’ll focus on medications for three reasons:
- Medications are among the most common causes of increased fall risk in older people.
- Medications are usually among the easiest risk factors to change, when it comes to falls in older adults.
- Medication-based risks are often missed by busy regular doctors. Older adults and family caregivers can make a big difference by being proactive in this area.
I want you to understand just what types of medications you and your doctors should be looking for, when you address medication review as part of fall prevention. This article will also explain exactly what to do, once you’ve identified any medications that are associated with falls.
Why review your medications for fall prevention?
The purpose of medication reviews is to identify medications that might be increasing fall risk.
Once you’ve identified these medications, healthcare providers are supposed to work with you to try to reduce or eliminate the use of such medications. This process is called “deprescribing” and you can learn more here: Deprescribing: How to Be on Less Medication for Healthier Aging.
At a minimum, during a medication review for fall prevention, you and your clinicians should reconsider these medications and confirm that the likely benefits outweigh the likely risks of taking the drug.
Later in this article, I will explain how you and your clinicians should consider stopping, switching, or reducing any medications that increase fall risk, or are otherwise risky for older adults.
But first, let me explain which medications you and your doctors should be looking out for.
3 categories of medication that should be reviewed to prevent falls
You may — or may not — be surprised to know that it’s extremely common for older adults to be taking medications that have been associated with increased fall risk.
These medications generally fall into one of two three broad categories:
- Medications that affect the brain. Health professionals often refer to these drugs as “psychoactives.” These are drugs that affect brain function. Many tend to cause some sedation or drowsiness.
- They can also cause or worsen confusion, especially in people with memory problems or Alzheimer’s disease.
- Most of them are included on this list: 4 Types of Medication to Avoid if You’re Worried About Memory.
- Most of these medications are listed in the 2019 American Geriatrics Society Updated Beers Criteria: Medications that Older Adults Should Avoid or Use with Caution.
- Medications that affect blood pressure. These are drugs that can cause or worsen a sudden fall in blood pressure (BP). A drop in BP — or chronically low BP — can increase fall risk.
- Older adults can easily experience a drop in blood pressure when they stand. This is called postural (or orthostatic) hypotension.
- Most medications for high blood pressure can cause or worsen postural hypotension.
- Medications such as tamsulosin (brand name Flomax) and related medications to improve urination can also cause postural hypotension.
- Medications that lower blood sugar. This is only a consideration for older adults with diabetes. But as this condition affects an estimated 25% of people over age 65, these medications are relevant to many seniors.
- People with diabetes have a higher risk of falls compared to others of the same age.
- Hypoglycemia (low blood sugar) due to medications is one of many factors that has been associated with falls in people with diabetes.
Below, I share my list of ten common types of medications associated with falls.
If you’ve been concerned about falls and want to request a medication review, this list will help you identify medications to discuss with your healthcare team.
10 Commonly Used Types of Medications that Increase Fall Risk in Older Adults
This list is mainly based on the CDC’s flyer Medications Linked to Falls and the American Geriatrics Society’s Clinical Practice Guidelines on Fall Prevention.
Medications that affect the brain (“psychoactives“)
1.Benzodiazepines. This class of medication is often prescribed to help people sleep, or to help with anxiety. They do work for this purpose, but they are habit-forming and have been associated with developing dementia.
- Commonly prescribed benzodiazepines include lorazepam, diazepam, temazepam, alprazolam (brand names Ativan, Valium, Restoril, and Xanax, respectively)
- Clinical research studies consistently find that benzodiazepines are associated with increased fall risk.
- For more on the risks of benzodiazepines, plus a handout proven to help seniors reduce their use of these drugs, see “How You Can Help Someone Stop Ativan.”
- Note that it can be dangerous to stop benzodiazepines suddenly. These drugs should always be tapered, under medical supervision.
2. Non-benzodiazepine prescription sedatives. These drugs are usually prescribed to treat insomnia or sleep difficulties.
- This group includes the “z-drugs”: zolpidem, zaleplon, and eszopiclone (brand names Ambien, Sonata, and Lunesta, respectively).
- These have been shown in clinical studies to impair balance — and thinking! — in the short-term.
3. Antipsychotics. These are medications originally developed to treat schizophrenia and other illnesses featuring psychosis symptoms. They are commonly prescribed to control difficult behaviors in Alzheimer’s and other dementias. (Learn more about why this is problematic in 5 Types of Medication Used to Treat Difficult Dementia Behaviors.) They are also sometimes prescribed to people with depression.
- Commonly prescribed antipsychotics are mainly “second-generation” and include risperidone, quetiapine, olanzapine, and aripiprazole (Risperdal, Seroquel, Zyprexa, and Abilify, respectively).
- The first-generation antipsychotic haloperidol (Haldol) is still sometimes used.
- Clinical research indicates that antipsychotics are associated with increased falls.
4. Anticonvulsants/Mood-stabilizers. Most of these drugs were originally developed to treat seizures. They are also used to stabilize mood in conditions such as bipolar disorder, and to treat difficult dementia behaviors. They can also be used to treat certain types of nerve pain.
- Valproic acid (brand name Depakote) is a mood stabilizer that is sometimes used to manage difficult behaviors in Alzheimer’s or other dementias.
- Clinical research suggests that anticonvulsants are associated with increased fall risk. They also tend to have many other problematic side-effects in older adults.
- Gabapentin (Neurontin) is another seizure medication that is often used to treat nerve pain. Some research suggests it may not affect balance as much as some other anticonvulsants.
5. Antidepressants. These are medications prescribed to treat depression. Some of them are also used to treat anxiety.
- Selective serotonin-reuptake inhibitors (SSRIs) include sertraline, citalopram, escitalopram, paroxetine, and fluoxetine (brand names Zoloft, Celexa, Lexapro, Paxil, and Prozac, respectively).
- Other antidepressants commonly used include mirtazapine, bupropion, and venlafaxine (brand names Remeron, Wellbutrin, and Effexor, respectively).
- Tricyclic antidepressants include amitryptiline and nortriptyline (brand names Elavil and Pamelor, respectively).
- These antidepressants are quite anticholinergic and are no longer often used to treat depression. They are still used to manage nerve pain.
- Trazodone is an older antidepressant that is now used almost exclusively as a mild sleep aid.
- Virtually all antidepressants have been associated with an increase in fall risk.
6. Opioid (narcotic) analgesics. Opioids are mainly used for the treatment of pain.
- Commonly used opioids include codeine, hydrocodone, oxycodone, morphine, fentanyl, and methadone.
- Opioids often cause drowsiness, as well as other side-effects.
- Clinical research on the association between opioids and increased fall risk in older adults has shown mixed results. A 2009 meta-analysis of medications and fall risk did not find that opioids were associated with falls. However some experts — including the CDC — still recommend that narcotic use be evaluated as part of fall risk management.
7. Anticholinergics. This group covers most over-the-counter sleeping aids, as well as a variety of other prescription drugs. These are medications that have the chemical property of blocking the neurotransmitter acetylcholine.
- A large number of drugs of different classes have strong anticholinergic activity. (See here for a comprehensive list.) They include:
- Sedating antihistamines, such as diphenhydramine (brand name Benadryl).
- The “PM” versions of over-the-counter analgesics (e.g. Nyquil, Tylenol PM); the “PM” ingredient is usually a sedating antihistamine.
- Medications for overactive bladder, such as the bladder relaxants oxybutynin and tolterodine (brand names Ditropan and Detrol, respectively).
- Medications for vertigo, motion sickness, or nausea, such as meclizine, scopolamine, or promethazine (brand names Antivert, Scopace, and Phenergan).
- Oral medications for itching, such as hydroxyzine and diphenhydramine (brand names Vistaril and Benadryl).
- Muscle relaxants, such as cyclobenzaprine (brand name Flexaril).
- “Tricyclic” antidepressants and also the SSRI paroxetine (brand name Paxil)
- Anticholinergics commonly cause sedation. They can also cloud thinking and have been associated with developing dementia.
- Clinical research on anticholinergics and fall risk has shown mixed results. A recent clinical study found that the association was not statistically significant. Still, given that anticholinergics can cause drowsiness and are risky for seniors for other reasons, many experts believe it’s reasonable to include them when reviewing medications for fall prevention.
Medications that affect blood pressure
8. Antihypertensives. A large number of different medications are commonly used to treat high blood pressure.
- For a list of antihypertensive medications, organized by class of drug, see “Types of Blood Pressure Medications.”
- Clinical research on blood pressure (BP) medications and fall risk has shown mixed results. Although one study found that BP medications were associated with injurious falls, another recent study found no association between BP medications and falls. Some research suggests that diuretics may be associated with higher fall risk than other classes of BP medication. Meta-analyses have generally been unable to confirm that antihypertensives increase fall risk.
- Despite the mixed clinical evidence, many geriatricians and other experts do recommend re-evaluating BP medications in older adults at high risk for falls. I describe a process for doing so here: 6 Steps to Better High Blood Pressure Treatment for Older Adults.
9. Other medications that affect blood pressure. There are some commonly used medications that are not usually prescribed for hypertension, but still lower BP or increase postural BP changes in many older people.
- Alpha-blockers are a class of medication now mainly used to help men with benign prostatic hypertrophy urinate. They include tamsulosin, terazosin, doxazosin, and prazosin (brand names Flomax, Hytrin, Cardura, and Minipress, respectively).
- A 2015 study found that the use of prostate-specific alpha blockers was associated with a higher risk of fall and fracture in older men.
Medications that lower blood sugar (for people diagnosed with diabetes)
10. Medications that lower blood sugar. Many older adults with diabetes take medications to keep their blood sugar from getting too high. Most diabetes medications can cause or worsen hypoglycemia (too low blood sugar).
- For a list of oral and injectable medications used to treat diabetes, see this MayoClinic.org page.
- Metformin (brand name Glucophage) is notable in that it causes minimal risk of hypoglycemia, unless it’s being taken in combination with insulin or other diabetes drugs. Recent research even suggests that metformin might have “antiaging” benefits.
- Research studies have found that hypoglycemia is associated with falls in older adults.
What to Do if You or Your Relative Is On These Medications
So what should you do if you discover that your older relative — or you yourself — are taking some of these medications?
Well, don’t panic. But do make sure that you and your healthcare team regularly re-evaluate your need and dosage of these medications.
Here’s what the CDC is telling healthcare providers to do about medications linked to falls:
- “STOP medications when possible.
- SWITCH to safer alternatives.
- REDUCE medications to the lowest effective dose.”
As a patient or concerned family member, it’s vital that you actively participate in this process with your healthcare providers.
So for every potentially risky medication you are taking, you’ll want to know:
- What problem is this medication meant to treat or manage? What other options are available to manage this problem? (Don’t forget to ask about non-drug treatments!)
- What are the benefits of continuing the medication? What are the likely risks and benefits of discontinuing the medication?
- Is a lower dose of this medication an option? What are the pros and cons of trying a lower dose?
Your health provider should be able to answer these questions for you. But many people find it’s also helpful to do a little research on their own. I especially recommend learning more about best practices for managing whatever health conditions are currently being treated by the medications above.
Now, although most of the medications above are indeed associated with increased fall risk, this doesn’t mean that it’s never appropriate for an older person to be taking these medications.
Sometimes a careful assessment of the likely benefits and burdens leads patients and their doctors to conclude that continuing a risky medication is, in fact, worthwhile.
But if you’ve been concerned about falls for yourself, or for an older loved one, you don’t want to be using a medication linked to falls unless you and your doctor have thought things through.
So take a good look at this list, and take a good look at the medications in your medicine cabinet. Make note of which ones should be discussed with your healthcare team. And then call your clinician and tell them you’d like to discuss your need for these medications.
By taking these steps, you’ll be in a much better position to benefit from medication review as part of your fall prevention plan.
Questions about medications and fall risk? Please post them below!
[This article was last updated in April 2020.]