What medications should be avoided or used with caution in older adults with a history of falls or conditions that increase fall risk, such as orthostatic hypotension?

High Fall Risk Medications in Older Adults

Older adults with fall history or orthostatic hypotension should avoid or use with extreme caution: benzodiazepines, antipsychotics, antidepressants (especially SNRIs), opioids, gabapentinoids, sedative-hypnotics (including zolpidem), anticholinergics (including hydroxyzine), and certain cardiovascular medications (alpha-blockers, vasodilators, diuretics). 1, 2

Highest Priority Medications to Avoid

Central Nervous System Depressants

• Benzodiazepines (including diazepam, temazepam) are strongly associated with falls, fractures, cognitive impairment, and increased mortality risk in older adults 1, 2, 3, 4

  • Meta-analysis shows benzodiazepines increase fall risk with OR 1.42 (95% CI 1.22-1.65) 4
  • Long-acting benzodiazepines carry higher risk (OR 1.81) compared to short-acting formulations (OR 1.27), though both should be avoided 4
  • FDA labeling specifically warns of falls and fractures, with increased risk when combined with alcohol or other sedatives 3

• Sedative-hypnotics including zolpidem significantly increase fall risk 1, 2, 5, 6

  • Zolpidem specifically increases fall probability with adjusted OR 2.59 (95% CI 1.16-5.81) in hospitalized elderly 5
  • Falls from zolpidem occur due to persistent sedation and sleepiness extending into daytime hours 6

• Antipsychotics (including risperidone) increase fall risk through orthostatic hypotension, sedation, and motor impairment 1, 2, 7, 4

  • Pooled OR for falls with antipsychotics is 1.54 (95% CI 1.28-1.85) 4
  • Risperidone specifically causes somnolence (41% at high doses), orthostatic hypotension, syncope, and cognitive/motor impairment 7
  • Particularly dangerous in dementia patients due to increased mortality risk 2

Antidepressants

• SNRIs must be avoided in patients with fall history or fractures 1, 2

  • Added to fall-risk criteria in 2019 Beers update with high-quality evidence 1

• SSRIs (including sertraline) increase fall risk with pooled OR 2.02 (95% CI 1.85-2.20) 4

  • Despite not being explicitly listed in fall-avoidance criteria like SNRIs, SSRIs show the highest fall risk among antidepressant classes in meta-analysis 4
  • Monitor for hyponatremia, bleeding risk, and drug interactions 2

• Tricyclic antidepressants increase falls through anticholinergic effects and orthostatic hypotension (OR 1.41) 2, 4

Opioids and Gabapentinoids

• Opioids should be avoided in fall-risk patients due to sedation, dizziness, and cognitive impairment 1, 2

  • Evidence level upgraded to "moderate" in 2019 Beers update 1

• Gabapentin and pregabalin increase fall risk, particularly in elderly, renally impaired, and those on polypharmacy 8, 2

  • Cause dizziness and somnolence requiring patient education about alertness impairment 8
  • Require dose adjustment in renal impairment 2

Anticholinergics

• Hydroxyzine causes sedation, psychomotor impairment, and anticholinergic effects (dry mouth, urinary retention, constipation) that persist into the next day 9
  • Older adults have increased sensitivity to these effects 9
  • Should be replaced with second-generation antihistamines whenever possible 9

Critical Drug-Drug Interactions That Amplify Fall Risk

• Never combine opioids with benzodiazepines due to severe respiratory depression and death risk 1, 2

• Avoid opioids with gabapentinoids except when transitioning from opioids to gabapentinoids as replacement therapy 1, 2

• Concurrent use of 3 or more CNS agents (antidepressants, antipsychotics, benzodiazepines, hypnotics, antiepileptics, opioids) dramatically increases fall risk 1, 2

Cardiovascular Medications Requiring Caution

• Diuretics (thiazides, loop diuretics) cause hypovolemia, orthostatic hypotension, dehydration, and electrolyte disturbances leading to falls 1

  • Particularly problematic in patients ≥75 years with ankle edema or poor mobility 1

• Calcium channel antagonists increase fall probability (OR 2.45,95% CI 1.16-4.74) through orthostatic hypotension 5

• Alpha-blockers and vasodilators cause orthostatic hypotension and syncope 1

• Nitrates increase orthostatic hypotension risk, requiring BP monitoring and use of smallest effective dose 1

Medications Requiring Enhanced Caution

• Dextromethorphan/quinidine has limited efficacy, significant drug interactions, and increased fall risk 1, 2

• Rivaroxaban in adults ≥75 years carries higher bleeding risk, which can precipitate falls 1, 2

• TMP-SMX with ACEIs/ARBs in reduced kidney function increases hyperkalemia risk and CNS effects 1, 2

Prevalence and Clinical Context

• 65-93% of older adults with fall-related injuries are taking FRIDs at the time of their fall 10

  • Antidepressants and sedative-hypnotics are the most commonly prescribed FRIDs in this population 10
  • FRID use typically does not decrease after a fall-related healthcare encounter, representing a major missed opportunity 10

• 50% of falls in hospitalized elderly occur within the first week of admission, requiring immediate medication review 5

Practical Implementation Algorithm

Step 1: Immediate Assessment

• Review all medications at every care transition using Beers Criteria 2
• Count total CNS medications (target <3 concurrent agents) 1, 2
• Assess orthostatic vital signs in patients on cardiovascular medications 1
• Check renal function for dose adjustments of gabapentinoids, ciprofloxacin, TMP-SMX 2

Step 2: Prioritized Deprescribing

• First priority: Remove benzodiazepines, opioid-benzodiazepine combinations, and opioid-gabapentinoid combinations 2
• Second priority: Discontinue or switch SNRIs, antipsychotics (especially in dementia), and sedative-hypnotics 1, 2
• Third priority: Replace hydroxyzine with second-generation antihistamines 9
• Fourth priority: Minimize diuretics, optimize cardiovascular medication dosing 1

Step 3: When Medications Cannot Be Stopped

• Start with lowest effective dose 8, 7
• Provide explicit patient education about fall risk, dizziness, and need for caution with alertness-requiring tasks 8
• Consider home safety assessment for high-risk patients 8, 9
• Monitor for adverse effects and reassess regularly for continued need 8
• Implement environmental fall prevention (remove hazards, improve lighting, appropriate footwear) 9
• Consider exercise interventions to improve strength and balance 9

Step 4: Special Monitoring

• Regular gait and balance assessment 9
• Orthostatic vital signs monitoring 1, 9
• Electrolyte monitoring with diuretics 1
• Renal function monitoring for renally cleared medications 2

Common Pitfalls to Avoid

• Do not assume short-acting benzodiazepines are safe - they still increase fall risk (OR 1.27) 4

• Do not substitute hydroxyzine at night for second-generation antihistamines during the day - hydroxyzine's sedative effects persist into the next day 9

• Do not overlook SSRIs - despite SNRIs being specifically listed in fall-avoidance criteria, SSRIs actually show higher fall risk in meta-analysis (OR 2.02 vs 1.41 for TCAs) 4

• Do not continue FRIDs after a fall without explicit reassessment - this represents standard practice failure, as most patients continue FRIDs unchanged after fall-related injuries 10

• Medication reduction alone may not prevent falls - must be combined with other fall prevention strategies for effectiveness 10