Muscle Relaxant Recommendations for Elderly Patients
Direct Recommendation
Baclofen is the preferred muscle relaxant for elderly patients, starting at 5 mg up to three times daily with a maximum tolerated dose of 30-40 mg per day, as most traditional muscle relaxants should be avoided in this population due to high risk of falls, anticholinergic effects, and sedation. 1
Why Most Muscle Relaxants Should Be Avoided
Muscle relaxants are listed in the American Geriatrics Society Beers Criteria as potentially inappropriate medications for older adults due to anticholinergic effects, sedation, and increased risk of falls 1
Most muscle relaxants do not directly relax skeletal muscle and have no evidence of efficacy in chronic pain, making their use questionable in elderly patients 2, 1
The effects of these drugs are nonspecific and not related to actual muscle relaxation, so they should not be prescribed under the mistaken belief that they relieve muscle spasm 2
Specific Agents to Avoid
Cyclobenzaprine
Cyclobenzaprine should be avoided in elderly patients as it is structurally identical to amitriptyline with comparable adverse effect profiles including CNS impairment, delirium, slowed comprehension, and falling 2, 1
Plasma concentrations of cyclobenzaprine are increased in the elderly, placing them at higher risk for CNS adverse events such as hallucinations and confusion, cardiac events resulting in falls, and drug-drug interactions 3
If cyclobenzaprine must be used, initiate with a 5 mg dose and titrate slowly upward, though this is generally not recommended 3
Carisoprodol
Carisoprodol should be completely avoided in elderly patients due to high risk of sedation and falls 1
This agent has been removed from the European market because of concerns about drug abuse 2, 1
Methocarbamol
Methocarbamol elimination is significantly impaired in patients with liver and kidney disease, which is common in elderly populations 1
It causes drowsiness, dizziness, and cardiovascular effects including bradycardia and hypotension 1
Orphenadrine
Orphenadrine is listed in the Beers Criteria as potentially inappropriate due to strong anticholinergic properties 1
It can cause confusion, anxiety, tremors, urinary retention, and cardiovascular instability, and should be used with extreme caution in patients with cardiac issues 1
Metaxalone
Metaxalone is contraindicated in patients with significant hepatic or renal dysfunction 1
It has multiple CNS adverse effects including drowsiness, dizziness, and irritability 1
Preferred Options
Baclofen (First-Line Choice)
Baclofen is the recommended muscle relaxant for elderly patients with a starting dose of 5 mg up to three times daily 1
Older persons rarely tolerate doses greater than 30-40 mg per day 1
Baclofen is a gamma amino butyric acid type B agonist with documented efficacy as a second-line drug for paroxysmal neuropathic pain and in patients with severe spasticity from CNS injury 2
Start with a low dose and gradually increase to minimize common side effects of dizziness, somnolence, and gastrointestinal symptoms 2
Critical pitfall: Abrupt discontinuation after prolonged use must be avoided due to risk of withdrawal symptoms including CNS irritability and potential for delirium and seizures 2, 1
Tizanidine (Alternative Option)
Tizanidine is a recommended alternative with a starting dose of 2 mg up to three times daily 1
Use with caution in renally impaired patients and monitor for orthostatic hypotension, sedation, and potential drug-drug interactions 1
The dose should be started at 2 mg and titrated slowly while monitoring for side effects 1
Alternative Approaches to Consider First
The American College of Physicians recommends considering non-pharmacological approaches for muscle spasm management first 1
For musculoskeletal pain, consider topical analgesics which may provide relief with fewer systemic side effects 1
Scheduled acetaminophen may be effective for mild to moderate musculoskeletal pain in elderly patients 1
If muscle spasm is suspected to be at the root of pain, consider benzodiazepines (though these also carry risks in the elderly) for management of anxiety or relief of muscle spasm, particularly when anxiety, muscle spasm, and pain coexist 2
Key Management Principles
Start with the lowest possible effective dose and use muscle relaxants for the shortest duration necessary 1
Avoid prescribing muscle relaxants with other medications that have anticholinergic properties 1
Be aware that many of these drugs are associated with greater risk for falls in older persons 2
For patients requiring treatment, baclofen remains the safest option with appropriate dose titration and monitoring for side effects 1