Caution: 7 Medications That May Increase Falls in Your Older Patient

September 26, 2019

Although not a DSM diagnosis, fear of falling is recognized as a common source of functional impairment and distress. The author presents 7 commonly prescribed medication categories that may increase fall risk in older adults.

In the elderly, falls are a common and important problem. After a fall-related injury, many older adults can have a fear of falling, a common geriatric condition marked by anxiety and low self-confidence about walking safely. The author presents 7 commonly prescribed medication categories that may increase fall risk in older adults.

Note: most of these medications also cause cognitive impairment and increase risk of delirium in older adults (eg, centrally acting anticholinergics, antihistaminergics, and sedatives).

Fear of falling is recognized as a common source of functional impairment and distress (and increased risk of falls) in older adults.

A case of an elderly woman.

Category 1: Benzodiazepines
Examples: clonazepam, alprazolam, diazepam, lorazepam
Action: Avoid; stop when feasible; taper to lower doses

Category 2: Other sedatives
Examples: “Z-drugs”: zalephon, zolpidem, eszopiclone
Action: Choose safer insomnia treatments, such as behavioral therapy, trazodone, or melatonin

Category 3: Strong, centrally acting anticholinergics and antihistamines used for non-CNS indications
Examples: Diphenhydramine; loratadine; overactive bladder medications (oxybutynin, tolterodine, fesoterodine); bowel medications (eg, hyoscyamine, dicyclomine)
Action: Stop: if treatment is needed, switch to a non-CNS penetrant antihistamine (cetirizine) or anticholinergic (trospium, loperamide)

Category 4: Tricyclic antidepressants
Examples: Particularly tertiary amine (amitriptyline, imipramine, doxepin)
Action: If a tricyclic is needed, use a secondary amine (nortriptyline, desipramine)

Category 5: Some antipsychotics
Examples: First-generation antipsychotics (high potency via inducing parkinsonism; low potency via parkinsonism and anticholinergic effects); olanzapine
Action: Use a second-generation antipsychotic with low or no anticholinergic effects (risperidone, aripiprazole, quetiapine)

Category 6: Some mood stabilizers and anti-epileptics
Examples: Lithium, valproate, carbamazepine, oxcarbazepine, topiramate (if at high doses/levels); barbiturates (such as phenobarbital and primidone); gabapentin or pregabalin (if at high doses)
Action: Use minimal effective dose; stop or avoid sedatives that can magnify fall risk

Category 7: Some psychotropic combinations
Examples: Paroxetine + bupropion; high-dose fluoxetine or duloxetine + bupropion; multiple sedatives
Action: Avoid or use reduced doses

For more information, see Psychotropic Drugs and Falls in Older Adults on which this slideshow is based.

Caution: 7 Medications That May Increase Falls in Your Older Patient

Eric J. Lenze, MD