Medication & fall risk

Benzodiazepine; causes sedation, ataxia, and impaired psychomotor function. Beers Criteria: all benzodiazepines increase risk of falls, fractures, cognitive impairment, and delirium in older adults. Shorter-acting agents are NOT safer than long-acting

Precautions

• —Avoid concurrent use with opioids
• —Use lowest effective dose
• —Taper to discontinue — do not stop abruptly
• —Do not drive

Ask your doctor about instead: SSRIs; Buspar (buspirone); Cognitive behavioral therapy

Tricyclic antidepressant (TCA); highly anticholinergic, causes sedation, orthostatic hypotension, and cardiac conduction abnormalities. Beers Criteria: strongly avoid — highly anticholinergic, increases fall and fracture risk. Often inappropriately used for nerve pain or sleep at low doses

Precautions

• —Avoid entirely in older adults
• —Do not use for sleep
• —If used for neuropathy, consider gabapentin or pregabalin instead

Ask your doctor about instead: Duloxetine (Cymbalta) for neuropathy; Gabapentin for nerve pain; Melatonin for sleep

Skeletal muscle relaxant; metabolized to meprobamate (a controlled substance with abuse potential). Causes profound sedation, dizziness, and ataxia. Beers Criteria: strongly avoid in older adults — limited efficacy, anticholinergic, risk of falls and fractures

Precautions

• —Avoid in older adults
• —High abuse and dependence potential
• —Do not combine with other CNS depressants

Ask your doctor about instead: Physical therapy; Heat/ice therapy; Acetaminophen

Long-acting benzodiazepine with very long half-life in elderly (up to 200 hours for active metabolites); causes prolonged sedation and accumulation. Beers Criteria: strongly avoid in older adults

Precautions

• —Strongly avoid in patients 65+
• —Extremely long half-life leads to accumulation
• —Causes significant fall risk even at low doses

Ask your doctor about instead: SSRIs for anxiety; Non-pharmacologic approaches

Long-acting benzodiazepine; accumulates in older adults due to decreased metabolism. Beers Criteria: all benzodiazepines increase risk of falls, fractures, and cognitive impairment. Continued use may lead to physical dependence

Precautions

• —Avoid in older adults whenever possible
• —Never combine with opioids
• —Slow taper required for discontinuation

Ask your doctor about instead: SSRIs; Anticonvulsant mood stabilizers

Skeletal muscle relaxant; structurally similar to TCAs. Causes sedation, dizziness, and anticholinergic effects. Beers Criteria 2023: skeletal muscle relaxants added as CNS-active agents that increase fall risk, especially with concurrent use of other CNS drugs

Precautions

• —Avoid in older adults
• —Highly sedating — do not drive
• —Do not combine with other CNS depressants

Ask your doctor about instead: Physical therapy; Stretching exercises; Heat/ice therapy; Acetaminophen

Long-acting benzodiazepine with half-life up to 100 hours in elderly; causes prolonged sedation, muscle weakness, and accumulation. Beers Criteria: strongly avoid in older adults

Precautions

• —Lowest dose possible due to accumulation risk
• —Avoid with other CNS depressants
• —Have someone assist when walking

Ask your doctor about instead: SSRIs; Gabapentin (for nerve pain)

First-generation antihistamine; highly anticholinergic. Beers Criteria: strongly avoid — highly anticholinergic, clearance reduced with advanced age. Cumulative anticholinergic exposure associated with increased risk of falls, delirium, and dementia

Precautions

• —Do not use as sleep aid in older adults
• —Avoid regular use
• —Consider total anticholinergic burden across all medications

Ask your doctor about instead: Second-generation antihistamines (loratadine, cetirizine); Melatonin for sleep; Nasal saline irrigation for allergies

Alpha-1 blocker; causes significant orthostatic hypotension, especially at initiation and dose increases. Beers Criteria: use with caution — may cause orthostatic hypotension and increase fall risk. Used for both hypertension and BPH

Precautions

• —Take at bedtime to minimize fall risk from first-dose syncope
• —Stand up slowly — three stages (lying → sitting → standing)
• —Monitor blood pressure after first dose

Ask your doctor about instead: Tamsulosin for BPH (less hypotensive); ARBs for hypertension

First-generation antipsychotic; causes extrapyramidal symptoms (muscle stiffness, tremors), orthostatic hypotension, and sedation. Beers Criteria: antipsychotics increase fall and fracture risk

Precautions

• —Avoid in older adults with dementia (black box warning for mortality)
• —Monitor for movement disorders
• —ECG monitoring for QT prolongation

Ask your doctor about instead: Non-pharmacologic behavioral interventions; Lower-dose atypical antipsychotics

Opioid; causes sedation, dizziness, confusion, and respiratory depression. Beers Criteria: opioids increase fall and fracture risk. Risk increases with dose and when combined with other CNS-active drugs

Precautions

• —Use lowest effective dose for shortest duration
• —Never combine with benzodiazepines
• —Use stool softener for constipation
• —Avoid driving

Ask your doctor about instead: Acetaminophen; NSAIDs (with caution); Physical therapy; Topical analgesics

First-generation antihistamine; highly anticholinergic. Beers Criteria: strongly avoid — cumulative anticholinergic exposure associated with increased risk of falls, delirium, and dementia. Often used for anxiety or itching inappropriately in older adults

Precautions

• —Avoid in older adults
• —Consider anticholinergic burden
• —Safer alternatives exist for both anxiety and pruritus

Ask your doctor about instead: SSRIs for anxiety; Topical corticosteroids for itching; Second-generation antihistamines

Tricyclic antidepressant (TCA); highly anticholinergic, orthostatic hypotension, sedation, and cardiac risk. Beers Criteria: strongly avoid in older adults — increases fall and fracture risk

Precautions

• —Avoid in older adults
• —High overdose risk
• —Multiple mechanisms increase fall risk

Ask your doctor about instead: SSRIs for depression; SNRIs; Cognitive behavioral therapy

Benzodiazepine; causes sedation, muscle relaxation, and impaired coordination. Beers Criteria: all benzodiazepines increase risk of falls, fractures, cognitive impairment, and delirium in older adults

Precautions

• —Avoid alcohol completely
• —Use lowest effective dose
• —Do not drive after taking

Ask your doctor about instead: SSRIs for anxiety; Buspar (buspirone); Cognitive behavioral therapy

Antipsychotic; causes significant sedation, weight gain, and metabolic effects; impairs balance and reaction time. Beers Criteria: antipsychotics increase fall and fracture risk

Precautions

• —Avoid driving
• —Monitor weight and blood sugar
• —Use fall prevention strategies

Ask your doctor about instead: Lower-dose options; Behavioral therapy

Anticholinergic for overactive bladder; causes confusion, dizziness, and blurred vision. Beers Criteria: strongly avoid in older adults — highly anticholinergic, increases risk of falls and cognitive decline. Cumulative anticholinergic exposure is particularly dangerous

Precautions

• —Consider mirabegron as safer alternative
• —Monitor for confusion
• —Avoid combining with other anticholinergics

Ask your doctor about instead: Mirabegron (Myrbetriq); Behavioral bladder training; Pelvic floor physical therapy

Opioid; causes drowsiness, dizziness, confusion, and slowed reaction time. Beers Criteria: opioids increase fall and fracture risk

Precautions

• —Do not drive
• —Avoid alcohol
• —Use stool softener for constipation
• —Never combine with sedatives

Ask your doctor about instead: Acetaminophen; NSAIDs (with caution); Physical therapy; Topical analgesics

SSRI with the most anticholinergic activity among SSRIs; causes sedation, dizziness, and hyponatremia. Beers Criteria: SSRIs increase fall and fracture risk. Paroxetine carries additional anticholinergic burden beyond other SSRIs

Precautions

• —Highest fall risk among SSRIs
• —Monitor sodium levels
• —Strong withdrawal symptoms — taper slowly

Ask your doctor about instead: Escitalopram (Lexapro) — less anticholinergic; Cognitive behavioral therapy

Anticonvulsant; causes ataxia, dizziness, nystagmus, and sedation, especially at higher serum levels. Narrow therapeutic window — toxicity easily reached in elderly due to decreased metabolism. Beers Criteria: anticonvulsants increase fall and fracture risk

Precautions

• —Monitor serum levels regularly (target 10-20 mcg/mL)
• —Report any gait instability or nystagmus immediately
• —Many drug interactions — review all medications

Ask your doctor about instead: Levetiracetam (Keppra) — fewer drug interactions; Lamotrigine (Lamictal)

First-generation antihistamine/antiemetic; highly anticholinergic. Beers Criteria: strongly avoid — anticholinergic, risk of falls, delirium, and dementia. Clearance reduced with advanced age

Precautions

• —Avoid in older adults entirely
• —Use alternative antiemetics
• —High anticholinergic burden contribution

Ask your doctor about instead: Ondansetron (Zofran) for nausea; Second-generation antihistamines for allergies

Antipsychotic; causes sedation, orthostatic hypotension, and dizziness; widely prescribed off-label for sleep in elderly at low doses. Beers Criteria: antipsychotics increase fall and fracture risk

Precautions

• —Lowest dose for sleep (25mg or less)
• —Do not combine with sleep aids
• —Stand up slowly

Ask your doctor about instead: Melatonin for sleep; Cognitive behavioral therapy

Antipsychotic; causes orthostatic hypotension, sedation, and extrapyramidal symptoms (movement disorders). Beers Criteria: antipsychotics increase fall and fracture risk

Precautions

• —Monitor blood pressure when standing
• —Report muscle stiffness or tremors
• —Fall risk assessment recommended

Ask your doctor about instead: Non-pharmacologic behavioral interventions; Lower-dose atypical antipsychotics

Benzodiazepine hypnotic; causes drowsiness, next-day sedation, and impaired motor coordination. Beers Criteria: all benzodiazepines increase fall and fracture risk

Precautions

• —Use for insomnia only short-term (under 2 weeks)
• —Do not combine with other CNS depressants
• —Remove tripping hazards from bedroom

Ask your doctor about instead: Melatonin; Cognitive behavioral therapy for insomnia; Low-dose trazodone

Nonbenzodiazepine hypnotic ('Z-drug'); causes drowsiness, impaired balance, and next-day grogginess; linked to nighttime wandering. Beers Criteria: all Z-drugs increase fall and fracture risk

Precautions

• —Take only when able to get 7-8 hours sleep
• —Remove tripping hazards from bedroom path
• —Use bed rail if needed

Ask your doctor about instead: Melatonin; Cognitive behavioral therapy for insomnia; Low-dose trazodone

Atypical antipsychotic; partial dopamine agonist. Can cause sedation, dizziness, and orthostatic hypotension. Beers Criteria: antipsychotics increase fall and fracture risk

Precautions

• —Monitor for akathisia (restlessness) which can paradoxically increase fall risk
• —Start at low dose in elderly
• —Monitor blood sugar and weight

Skeletal muscle relaxant; causes muscle weakness, sedation, dizziness, and ataxia. Beers Criteria 2023: skeletal muscle relaxants increase fall risk as CNS-active agents. Abrupt discontinuation can cause hallucinations and seizures

Precautions

• —Do not stop abruptly (serious withdrawal)
• —Avoid driving
• —Use lowest effective dose

Anticonvulsant; causes dizziness, ataxia, sedation, and blurred vision. Induces its own metabolism and interacts with many drugs. Beers Criteria: anticonvulsants increase fall and fracture risk

Precautions

• —Monitor serum levels and liver function
• —Check for drug interactions (CYP450 inducer)
• —Report any rash immediately (Stevens-Johnson risk)

SNRI; active metabolite of venlafaxine. Causes dizziness, orthostatic hypotension. Beers Criteria 2023: SNRIs associated with increased fall and fracture risk

Precautions

• —Monitor blood pressure
• —Do not stop abruptly
• —Dose adjustment needed for kidney impairment

Cholinesterase inhibitor for Alzheimer's disease; can cause bradycardia, syncope, and dizziness. May increase risk of falls due to syncopal events. Also associated with insomnia and muscle cramps

Precautions

• —Monitor heart rate (risk of bradycardia)
• —Report fainting or near-fainting episodes
• —Take in morning to reduce insomnia risk

Serotonin-norepinephrine reuptake inhibitor (SNRI); may cause dizziness, orthostatic hypotension, and hyponatremia. Beers Criteria 2023: SNRIs added to list of antidepressants associated with increased fall and fracture risk. Evidence suggests SNRIs may increase falls risk similar to SSRIs

Precautions

• —Monitor blood pressure (can increase or decrease)
• —Monitor sodium levels
• —Do not stop abruptly — taper

Ask your doctor about instead: SSRIs (lower fall risk than TCAs)

SSRI; generally well-tolerated but can cause dizziness and hyponatremia. Beers Criteria: SSRIs increase fall and fracture risk

Precautions

• —Monitor for low sodium
• —Report unusual tiredness or confusion
• —Do not stop abruptly

Ask your doctor about instead: Bupropion (Wellbutrin) — lower fall risk

SSRI with very long half-life (4-6 days); may cause agitation, insomnia, and dizziness in elderly. Beers Criteria: SSRIs increase fall and fracture risk

Precautions

• —Start at half usual adult dose
• —Monitor for agitation or anxiety
• —Long washout period if switching meds

Increases urination frequency, causing rush to bathroom (especially at night); may cause dehydration and electrolyte imbalance

Precautions

• —Take in morning to reduce nighttime bathroom trips
• —Monitor potassium
• —Use night light in bathroom path

Gabapentinoid; causes dizziness, drowsiness, and unsteadiness; risk increases with dose and age. Beers Criteria 2023: gabapentinoids added as CNS-active drugs that increase fall risk when combined with other CNS agents

Precautions

• —Start low, go slow
• —Do not stop abruptly
• —Avoid driving until you know how it affects you

Sulfonylurea; can cause hypoglycemia (low blood sugar), leading to dizziness, confusion, and falls

Precautions

• —Monitor blood sugar before driving
• —Eat meals on schedule
• —Recognize hypoglycemia symptoms

Hypoglycemia risk; severe low blood sugar can cause loss of balance, confusion, and consciousness

Precautions

• —Check blood sugar before activities
• —Keep glucose tablets nearby
• —Wear medical ID

Tricyclic antidepressant (TCA); less anticholinergic than amitriptyline but still causes sedation and orthostatic hypotension. Beers Criteria: TCAs increase fall and fracture risk. Caution in older adults with history of falls

Precautions

• —Monitor blood pressure when standing
• —Start at lowest dose
• —Avoid with other anticholinergics

Ask your doctor about instead: SSRIs; SNRIs; Physical therapy for pain

Gabapentinoid; causes dizziness and somnolence, especially in elderly. Beers Criteria 2023: gabapentinoids increase fall risk when combined with other CNS agents

Precautions

• —Lower dose for elderly
• —Monitor for edema
• —Avoid driving

SSRI; may cause dizziness, hyponatremia (low sodium) in elderly, and sleep disturbance. Beers Criteria: SSRIs associated with increased fall and fracture risk

Precautions

• —Monitor sodium levels in first weeks
• —Take in morning if causing insomnia
• —Watch for increased anxiety initially

Alpha-1 blocker selective for prostate; can cause orthostatic hypotension, dizziness, and syncope, especially in elderly. Intraoperative floppy iris syndrome during cataract surgery is a known complication

Precautions

• —Stand up slowly from sitting/lying
• —Inform eye surgeon before cataract surgery
• —Monitor blood pressure regularly

Anticholinergic for overactive bladder; less anticholinergic than oxybutynin but still increases fall risk. Beers Criteria: avoid anticholinergics for urinary incontinence — may decrease urinary flow and cause urinary retention

Precautions

• —Mirabegron preferred over anticholinergics
• —Monitor for cognitive side effects
• —Assess total anticholinergic burden

Ask your doctor about instead: Mirabegron (Myrbetriq); Behavioral therapy; Pelvic floor exercises

Anticonvulsant; causes dizziness, ataxia, somnolence, and confusion. Can cause metabolic acidosis and visual disturbances. Beers Criteria: anticonvulsants increase fall and fracture risk

Precautions

• —Start low and titrate slowly
• —Stay well hydrated (kidney stone risk)
• —Monitor for word-finding difficulty and confusion

Opioid agonist + SNRI activity; causes dizziness, sedation, and confusion. Lowers seizure threshold. Beers Criteria: opioids increase fall and fracture risk

Precautions

• —Lower seizure threshold — use with caution
• —Avoid with SSRIs/SNRIs (serotonin syndrome risk)
• —Do not combine with other CNS depressants

Ask your doctor about instead: Acetaminophen; Physical therapy; Topical analgesics

Sedating antidepressant; commonly used off-label for insomnia in elderly. Causes drowsiness, orthostatic hypotension, and next-day sedation. Sedative effects increase fall risk, especially during nighttime bathroom trips

Precautions

• —Take at bedtime only
• —Avoid combining with other sedatives
• —Start at 25-50mg for sleep in elderly
• —Watch for orthostatic hypotension

SNRI; can cause dizziness, orthostatic hypotension, and dose-dependent hypertension. Beers Criteria 2023: SNRIs associated with increased fall and fracture risk

Precautions

• —Monitor blood pressure regularly
• —Do not stop abruptly (severe withdrawal)
• —Take with food to reduce nausea

May cause peripheral edema (swelling in ankles) and dizziness

Precautions

• —Elevate legs when sitting
• —Report swelling to doctor
• —Stand up slowly

May cause orthostatic hypotension (blood pressure drop when standing) in some patients

Precautions

• —Stand up slowly
• —Monitor blood pressure when changing positions
• —Stay hydrated

Ask your doctor about instead: ACE inhibitors (ARBs like Losartan have fewer falls reports)

Generally well-tolerated; minimal fall risk compared to other BP meds

Precautions

• —Monitor potassium levels
• —Stay hydrated in hot weather

Generally safe; low blood sugar (hypoglycemia) is main fall risk if combined with sulfonylureas or insulin

Precautions

• —Monitor blood sugar regularly
• —Eat regular meals
• —Carry fast-acting glucose

Can cause dizziness, fatigue, and bradycardia (slow heart rate)

Precautions

• —Check pulse before taking
• —Avoid sudden position changes
• —Do not skip doses