Have you been concerned about falls for yourself, or for an aging parent?
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:
- Ask your doctor or pharmacist to review your medicines.
- Begin an exercise program to improve leg strength and balance.
- 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, a 2020 meta-analysis of opioids did find an association with falls, fall injuries, and fractures.
- Most experts — including the CDC — 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 2015 clinical found that the association was not statistically significant. However, more recent studies (such as here and here) have found an association.
- Given that anticholinergics can cause drowsiness and are risky for older adults 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. (They are also often used for other cardiac conditions.)
- For a list of cardiac medications, including blood pressure medications, organized by class of drug, see “Types of Heart 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, a more 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 October 2022.]
This is a great article. My mom is 95 now, but 10 years ago when she was suffering from dizziness I visited her doctor with her. Somehow I intuitively knew something was “off”. I took her to another doctor who looked at her medications, and within 5 min, said, “she’s overprescribed”. The primary culprit was blood pressure medication (Benicar HCT). He reduced the dose gradually, until she didn’t need any, and we monitored. Later when blood pressure started inching up, he put her on a tiny dose of another blood pressure med. Only 6 months later, her original doctor closed his once thriving practice, and though the grapevine we heard he had either Parkinsons or Alzheimers, which might have explained the over prescribing. I tell everyone I know to check those medications. I sometimes think it would be wise to find a geriatric pharmacist. I still cannot believe how overprescribed she was and how many falls she took before we figured it out.
Maria D says
My husband is 83 with mixed dementia. I have been vigilant for 6 years in questioning and minimizing dosages and number of his prescriptions and luckily he has a geriatric GP who listens to me since she knows I seem him 24/7 and she doesn’t.
The biggest concern for me now are the antibiotics used for a UTI which men of his age can get frequently. Either it is 100mg 2x a day or 500mg 4 times a day. No matter what type of antibiotic dosage, by the end of the series, he is wobbly and falls…not to mention weak during the process. Crenberry pills can somewhat help to avoid UTIs but not completely in his case.
Nicole Didyk, MD says
It’s great to hear that you have a trusting relationship with your husband’s doctor.
It’s not unusual for a urinary tract infection to make a frail older adult feel wobbly and more likely to fall, regardless of the treatment. TI that not every positive urine culture needs to be treated either, as Dr. K explain in this article: https://betterhealthwhileaging.net/urine-bacteria-without-uti-in-elderly/
There isn’t great evidence for cranberry juice in urinary tract infection,but drinking water and other sugar free fluids can help.
Chuck Edge says
I understand Duke University is working on a new knee gel that is supposed to be far superior to what is currently available. I’ve been told I might need knee replacement in the next few years and see this new gel as a possible way to avoid surgery.
What do you know about this? Any idea when it might be available to be used in the general public? Will there, or are there, any human trials that I could sign up for?
Nicole Didyk, MD says
I found this article about the development of a synthetic gel that mimics the function of cartilage in the knee joint: https://www.today.duke.edu/2020/06/lab-first-cartilage-mimicking-gel-strong-enough-knees. That sounds very exciting! The article indicates that the new compound has been through lab test, but it will probably be a few years before it’s ready to be marketed to humans.
I would contact Duke University to see if they’re looking for test subjects if you’re interested. The timeline might just work out for you!
Jessikia Westmoland says
My boyfriend is 60 years old and works in construction. He is a bigger man writing in at about 220 and 6’3. He is on furosemide, Pravastatin, potassium, Lisinopril, Duloxetine, Glipizide, Janumets, Neurotin, and baby aspirin. He has high blood pressure and type two diabetes. He eats for the lost part pretty healthy. He doesn’t use insulin or check his sugar leves, well, hardly ever. He wears compression socks due to poor circulation in legs and they do turn purple, dark purple if I don’t stay on top of him. He’s active. He had had back surgery due to siatica nerve issue about 15 years ago. A few weeks ago out of the blue he started falling out of no where. His right leg just gives out. He said he will go to step on it and it just “isn’t there.” Its getting worse and the falls are more frequent. I dress him now and put his shoes on and have to help him in and out of bed or vehicle and now he can barely put pressure on his right leg if at all. I’m horrified he is going to fall on the ice we currently have outside while working and hit his head and really hurt himself or die. What do I do? I’m 26 years younger than he is and I don’t know anything about any of this stuff and he’s a stubborn mule getting to do anything much less go to the doctor. Help! Any advice will be appreciated.
Nicole Didyk, MD says
I would be very concerned if I heard about sudden weakness or lack of feeling in a limb, especially in someone who has diabetes and “poor circulation” and would encourage them to get immediate medical attention. Such a person may be at risk for a stroke, blocked artery, blood clot, or compression of a nerve at the level of the spinal cord or the nerves coming off the spinal cord.
Falls can also be related to medications and many other issues.
Sometimes individuals are “stubborn” as a way of masking fear when it comes to health problems. Not being able to walk without help will soon lead to more health challenges in an older adult and should be addressed before it progresses or causes other complications.
According to NIH, falling is also more common among people with untreated hearing loss.
Nicole Didyk, MD says
Thanks for mentioning hearing loss. According to a recent paper that I read, those with hearing loss may have an increased odds of falling of 2.39. Another good reason to get one’s hearing checked and use an assistive device if needed.
Raymond Rizzo says
Hello and, as always, thank you for the helpful articles you post and the time you take to do it.
I have White Matter Hyperintensities and I saw a study a year ago that anticholergenics can cause them to increase and/or be harmful to your brain in some way. My question is, would the short-term use (i.e. 7-10 days) of a medicine like Meclizine (for vertigo symptoms) or Flexoril (for back spasms) be a cause of concern or are those issues only related to long term use of those types of medicine?
Nicole Didyk, MD says
It does appear that anticholinergic medication use increases the risk of dementia, and has been associated with atrophy (shrinkage) and other brain changes. This is based largely on longitudinal population studies, following groups of people over time to look at the frequency of certain outcomes, and correlating these outcomes with exposures to medications.
It does seem that there is a dose-response relationship, such that the greater and more prolonged the exposure, the higher the risk of dementia, so a smaller dose of an anticholinergic medication is less likely to be harmful. Still, we definitely discourage the use of anticholinergic medication in older adults, unless the potential benefit is greater than the potential harm, based on the individual’s goals and preferences.
The other thing to keep in mind is that anticholinergic medications aren’t just psychiatric ones, and can include things like furosemide and digoxin, so if one is concerned about reducing anticholinergic drug burden, a chat with a pharmacist is a good idea.
Erin oday says
My mom died home alone from a supposed caddiac arrest from a fall. She was on almost all of those medications you mentioned rescribed by her doctor when she died. Like 12-15 different pills a day some more than once a day. I didnt realizehow much crap they were having her taketil i cleaned her apartment after she died and found them along with all of her scripts etc.
Nicole Didyk, MD says
I’m sorry to hear about your mom, and you make a good point that many older adults are on medications that can have deleterious side effects. Here’s the latest on some guidelines about medications to avoid in older adults.
Sandra Crouse says
Lately i have fallen several times and i do not understand why. I also find it is very hard to get up from a sitting or squatting position. I am 71 years old.
Nicole Didyk, MD says
Sorry to hear about your falls. When someone describes difficulty getting up, it sounds like it could be muscle weakness, but falls can have multiple causes. I think this article might be helpful.