What medication is recommended for an elderly patient with dementia and frequent falls?

Medication Selection for Dementia in Elderly Patients with Frequent Falls

In elderly patients with dementia and frequent falls, cholinesterase inhibitors (donepezil, rivastigmine, or galantamine) should be initiated or continued as first-line dementia treatment, with careful attention to side effect profiles—specifically avoiding rivastigmine if the patient cannot tolerate dizziness or weight loss, as these increase fall risk. 1

Critical Medication Selection Framework

Step 1: Initiate or Continue Dementia-Specific Pharmacotherapy

Pharmacological treatment for dementia should be initiated or continued regardless of frailty status or fall history. 1 The practitioner must evaluate the potential risks and benefits of each medication in relation to the patient's overall health, treatment goals, and specifically their fall risk. 1

Cholinesterase Inhibitor Selection Based on Fall Risk:

• Donepezil is the preferred first-line agent for patients with frequent falls, as it may actually improve gait parameters including gait velocity and stride time variability, potentially reducing fall risk rather than increasing it. 2, 3

• Avoid rivastigmine in patients with frequent falls if possible, as it produces side effects including dizziness and weight loss that directly increase fall risk. 1 If rivastigmine must be used, the practitioner should identify whether potential cognitive benefits outweigh the risks and side effects for this individual. 1

• Donepezil dosing: Start at 5 mg/day, with potential titration to 10 mg/day after 4-6 weeks if tolerated. 4, 5, 3 The 10 mg dose provides marginally larger benefits than 5 mg, though withdrawal rates are slightly higher. 4

Step 2: Address Fall Risk Through Multimodal Intervention

Individuals with dementia, frailty, and high fall risk require personalized, multimodal intervention based on specific risk factors. 1 Key intervention strategies include:

• Physical exercise programs incorporating aerobic, strength, balance, and stability training (50-60 minutes daily, distributed throughout the day). 1

• Medication review and deprescribing: Systematically review all medications using STOPP/START or Beers criteria, discontinuing anticholinergics, benzodiazepines, antipsychotics, and opioids when possible due to their fall-potentiating effects. 1

• Management of comorbidities: Treat pain, infections (especially UTI and pneumonia), constipation, urinary retention, and sensory deficits (hearing and vision). 1, 6

• Environmental modifications: Install grab bars, improve lighting, remove hazards, and use mobility assistance devices. 1, 6

Step 3: Monitor Safety and Effectiveness

In individuals with high levels of frailty and fall risk, close monitoring of the safety, tolerability, and effectiveness of dementia treatment is essential. 1

• Assess fall frequency, gait parameters, and balance at baseline and regularly during treatment. 1

• If the medication is ineffective or causing substantial adverse effects (including increased falls), it should be withdrawn or alternative options explored. 1

• Conduct comprehensive gait assessment using computerized methods where available. 1

• Perform osteoporosis and fracture risk assessments for all individuals with dementia and frailty. 1

Critical Medications to AVOID in Fall-Prone Patients

• Benzodiazepines: Increase fall risk, cause paradoxical agitation in 10% of elderly patients, worsen cognitive function, and should be avoided except for alcohol/benzodiazepine withdrawal. 6, 1

• Anticholinergic medications (diphenhydramine, oxybutynin, cyclobenzaprine): Worsen confusion, agitation, and increase fall risk. 1, 6

• Antipsychotics: Should only be used when the patient is severely agitated, threatening substantial harm to self or others, and behavioral interventions have failed—never for fall prevention or mild behavioral symptoms. 6 All antipsychotics increase mortality risk 1.6-1.7 times and significantly increase fall risk. 6

Common Pitfalls to Avoid

• Do not withhold cholinesterase inhibitors solely due to fall history—the evidence suggests donepezil may actually improve gait stability. 2

• Do not add multiple medications simultaneously without first addressing reversible causes of falls (pain, infection, polypharmacy, environmental hazards). 1, 6

• Do not use antipsychotics for behaviors unlikely to respond (unfriendliness, poor self-care, memory problems, repetitive questioning, wandering). 6

• Do not continue medications indefinitely without reassessment—review need at every visit and attempt deprescribing when appropriate. 1, 6