Can an elderly patient take a muscle relaxer, such as cyclobenzaprine (Flexeril) or methocarbamol (Robaxin), safely?

Can Elderly Patients Take Muscle Relaxers?

Elderly patients should generally avoid muscle relaxants due to significant risks of falls, fractures, emergency department visits, and hospitalizations, but if absolutely necessary, baclofen is the preferred agent starting at 5 mg three times daily with slow titration. 1

Why Muscle Relaxants Are Problematic in the Elderly

• The American Geriatrics Society lists muscle relaxants in the 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 1
• Elderly patients using skeletal muscle relaxants have a 32% increased risk of injury (adjusted OR 1.32,95% CI 1.16-1.50) compared to non-users 2
• Muscle relaxants are associated with a 40% increased risk of fractures in older adults (OR 1.40,95% CI 1.15-1.72), comparable to benzodiazepines 3
• Emergency department visits increase 2.25-fold (AOR 2.25,95% CI 2.16-2.33) and hospitalizations increase 1.56-fold (AOR 1.56,95% CI 1.48-1.65) in elderly patients prescribed skeletal muscle relaxants 4

Specific Agents to Avoid in the Elderly

Cyclobenzaprine (Flexeril)

• The American Geriatrics Society recommends avoiding cyclobenzaprine in elderly patients as it is structurally similar to tricyclic antidepressants with comparable adverse effect profiles 1
• The FDA label specifically warns that elderly patients are at higher risk for CNS adverse events such as hallucinations and confusion, cardiac events resulting in falls, and drug-drug interactions 5
• Cyclobenzaprine plasma concentrations are increased in the elderly, and if used, should be initiated at 5 mg with slow upward titration 5
• Cyclobenzaprine is associated with a 22% increased risk of injury in elderly patients (OR 1.22,95% CI 1.02-1.45) 2
• Hold cyclobenzaprine on the day of surgery due to potential interactions with anesthetics and sedatives 6

Methocarbamol (Robaxin)

• Methocarbamol elimination is significantly impaired in patients with liver and kidney disease 1
• Methocarbamol causes drowsiness, dizziness, and cardiovascular effects including bradycardia and hypotension 1
• Methocarbamol is associated with a 42% increased risk of injury in elderly patients (OR 1.42,95% CI 1.16-1.75) 2

Carisoprodol (Soma)

• Carisoprodol should be avoided in elderly patients due to high risk of sedation and falls, and has been removed from the European market due to concerns about drug abuse 1
• Carisoprodol is classified as a controlled substance with substantial abuse and addiction potential 6
• Carisoprodol is associated with a 73% increased risk of injury in elderly patients (OR 1.73,95% CI 1.04-2.88) 2
• If time permits, consider tapering off or switching to an alternative agent before surgical procedures 6

Other Agents to Avoid

• Metaxalone is contraindicated in patients with significant hepatic or renal dysfunction and has multiple CNS adverse effects 6, 1
• Orphenadrine is listed in the Beers Criteria as potentially inappropriate for older adults due to strong anticholinergic properties 1
• Tizanidine should be avoided in older adults due to significant sedation and hypotension, and is contraindicated in elderly patients per SPAQI guidelines 6, 7

If a Muscle Relaxant Is Absolutely Necessary

Baclofen: The Preferred Agent

• The American Geriatrics Society recommends baclofen as the preferred muscle relaxant for elderly patients requiring such therapy 1
• Start at 5 mg three times daily and titrate gradually, increasing weekly by small increments, to minimize dizziness, somnolence, and gastrointestinal symptoms 1
• Maximum tolerated dose in elderly patients is typically 30-40 mg per day; older persons rarely tolerate higher doses 1
• Baclofen has documented efficacy as a GABA-B agonist for muscle spasm and spasticity, particularly in CNS injury and neuromuscular disorders 1, 8

Critical Safety Warning for Baclofen

• Never discontinue baclofen abruptly—requires slow tapering to avoid withdrawal symptoms including delirium, seizures, and CNS irritability 1, 9
• Abrupt discontinuation after prolonged use can cause severe CNS irritability and must be avoided 1

Clinical Decision Algorithm

Step 1: Consider Non-Pharmacological Approaches First

• The American College of Physicians recommends considering non-pharmacological approaches for muscle spasm management before initiating any muscle relaxant 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

Step 2: If Pharmacological Treatment Is Required

• First choice: Baclofen 5 mg three times daily, titrate slowly 1
• Monitor for dizziness, somnolence, gastrointestinal symptoms, and fall risk 1
• Ensure patient can tolerate maximum dose of 30-40 mg per day before increasing further 1

Step 3: Duration of Therapy

• All muscle relaxant trials were 2 weeks or less in duration, indicating these agents should only be used short-term 7
• There is insufficient evidence for chronic use of any muscle relaxant for musculoskeletal pain 7
• Use for the shortest duration necessary 1

Key Pitfalls to Avoid

• Do not prescribe muscle relaxants with other medications that have anticholinergic properties 1
• Do not use muscle relaxants believing they relieve muscle spasm unless true spasm is suspected 1
• Avoid in frail patients with mobility deficits, weight loss, weakness, or cognitive deficits 6
• Monitor closely for falls, as all muscle relaxants are associated with greater fall risk in older persons 1, 9
• The number needed to harm is 333—meaning 333 elderly patients need to be treated with a skeletal muscle relaxant to result in 1 additional injury 10