Medication and Falls
Original Editors - Scott Buxton
Top Contributors -Scott Buxton, Lucinda hampton, Alexandra Stead, Sai Kripa, Kim Jackson, WikiSysop, Evan Thomas, Tolulope Adeniji and Chelsea Mclene
Introduction
Older adults aged 65 years and over are at increased risk of falls, which represent a growing public health concern in ageing populations worldwide.[1] In 2021, there were approximately 45.6 million new falls globally, reflecting a 182% increase since 1990.[1] Falls are associated with increased rates of morbidity and mortality in this age group, and fall-related death rates have been rising annually for at least two decades.[2] Multiple risk factors contribute to falls, including age, sex, comorbidities, medications, environmental hazards, vision impairment, and impaired balance.[1]
Among these risk factors, medications are particularly significant because they are both a common contributor to falls risk and one of the most modifiable factors available to clinicians.[3] Addressing medication-related falls risk is therefore a key priority in falls prevention for older adults.[4]
Medication and Falls
- Medications are among the most common causes of increased falls risk in older adults.[3]
- Medications are often one of the most modifiable falls risk factors in this population.[4]
- Medication-related risks are frequently overlooked in busy clinical settings. Older adults, family carers, physiotherapists, and other allied health professionals can play an active role in identifying and raising these concerns.[5]
What is Polypharmacy?
Polypharmacy is most commonly defined as the concurrent use of five or more medications.[6] This threshold is the most widely used in research and is the definition applied throughout this page.[7] The prevalence of polypharmacy among adults aged 65 and over ranges from 30% to 60% globally, and is expected to rise as life expectancy continues to increase.[8]
It is important not only to consider the number of medications a person is taking, but also the type, as different drug classes carry different levels of falls risk.[9] The presence of multiple falls risk-increasing drugs in a person's prescription is an independent risk factor for falls, even in those taking few medications overall.[9]
A 2017 longitudinal study reported that almost one-third of people taking five or more medications experienced a significantly increased rate of falls (21%) over a two-year period, and concluded that detailed, standardised assessment of polypharmacy in real-world settings is essential.[5]
Medications Associated with Increased Falls Risk
As physiotherapists, it is important to be aware of which medications may affect a person's safety. While prescribing and deprescribing fall outside the physiotherapist's direct scope of practice, understanding the effects of specific drug classes is clinically valuable, particularly for those working in triage roles or as part of a multidisciplinary team (MDT).[4]
If a physiotherapist has concerns about the type or number of medications a person is taking, the appropriate action is to raise this with medical colleagues, correspond with the person's general practitioner, or escalate via an MDT meeting.[4]
In broad clinical terms, three categories of medication increase falls risk:[10]
- Medications that affect the brain and central nervous system (CNS)
- Medications that affect blood pressure and cardiovascular function
- Medications that lower blood glucose
Note: Most diabetes medications can cause or worsen hypoglycaemia (abnormally low blood glucose), which is a recognised falls risk.[10] These are not included in the tables below but should be considered as part of a comprehensive medication review.
More specifically, two principal classes of medication are consistently associated with increased falls risk:[3][11][12]
- Psychotropic drugs (acting on the CNS)
- Drugs acting on the heart and circulation
Psychotropic Drugs
Psychotropic medications act on the CNS and are among the most strongly implicated drug classes in falls risk in older adults.[13] Orthostatic hypotension — a drop in blood pressure upon standing — is a particularly common mechanism across this drug class.[10]
| Medication Group | Overall Risk Category | Commonly Used Medications | Effects on Risk |
|---|---|---|---|
| Sedatives |
HIGH RISK Can cause falls alone[14] |
Lorazepam, Temazepam, Nitrazepam (note: –epam suffix) |
Drowsiness, slowed reactions, impaired balance.[14] Benzodiazepines increase falls risk in older adults and should be avoided where possible.[15] |
| Sedating Antidepressants | Amitriptyline, Nortriptyline | Orthostatic hypotension (a drop in blood pressure upon standing), drowsiness, slowed reactions. Associated with a significantly increased rate of falls.[14][11] | |
| Monoamine Oxidase Inhibitors (MAOIs) | Phenelzine, Moclobemide | Severe orthostatic hypotension.[14] | |
| Antipsychotics (for psychosis and agitation) | Haloperidol, Chlorpromazine, Olanzapine | Orthostatic hypotension, slowed reflexes, loss of balance.[14][11] | |
| Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin and Noradrenaline Reuptake Inhibitors (SNRIs) |
MODERATE RISK Can cause falls in combination[14] |
Fluoxetine, Sertraline, Paroxetine, Venlafaxine, Duloxetine | Increased falls risk with fractures; orthostatic hypotension, bradycardia (abnormally slow heart rate), impaired sleep quality.[14][11] |
| Opioid Analgesics |
HIGH RISK Can cause falls alone[14] |
Codeine, Morphine, Tramadol | Sedation, slowed reactions, impaired balance, delirium.[14][11] |
| Anti-Epileptics | HIGH RISK[14] | Phenytoin, Carbamazepine, Phenobarbitone | Cerebellar damage (affecting coordination), ataxia (loss of full control of bodily movements), slowed reactions.[14] |
| MODERATE RISK[14] | Sodium Valproate, Gabapentin | Some association with falls risk.[14] | |
| Parkinson's — Dopamine Agonists | HIGH RISK[14] | Ropinirole, Pramipexole | Delirium, orthostatic hypotension.[14] |
| Parkinson's — MAO-B Inhibitors | Selegiline | Orthostatic hypotension. Note: difficult to assess independently given the inherently high falls risk associated with Parkinson's disease itself.[14] | |
| Muscle Relaxants | MODERATE RISK[14] | Baclofen | Reduced muscle tone, sedation.[14] |
| Vestibular Sedatives | POSSIBLE CAUSES[14] | Prochlorperazine, Cinnarizine, Betahistine | Prochlorperazine acts as a dopamine antagonist and may cause movement disorders with long-term use; also sedating.[14] |
| Anticholinergics Acting on the Bladder | Oxybutynin, Solifenacin, Tolterodine | Known CNS effects including confusion and sedation.[14][11] |
Drugs Acting on the Heart and Circulation
Cardiovascular and antihypertensive medications are associated with falls risk primarily through mechanisms including hypotension (low blood pressure), bradycardia (abnormally slow heart rate), and dehydration.[3] Orthostatic hypotension is particularly implicated as a falls mechanism in this drug class.[16]
| Medication Group | Overall Risk Category | Commonly Used Medications | Effect on Risk |
|---|---|---|---|
| Alpha Receptor Blockers | HIGH RISK[3] | Doxazosin, Tamsulosin, Indoramin | Severe orthostatic hypotension, urinary retention.[14][3] |
| Centrally Acting Alpha-2 Receptor Agonists | Clonidine, Moxonidine | Severe orthostatic hypotension, sedation.[14] | |
| Thiazide Diuretics | Bendroflumethiazide, Metolazone | Weakness due to low potassium, hyponatraemia (low blood sodium), orthostatic hypotension.[14][3] | |
| Loop Diuretics | MODERATE RISK[3] | Furosemide, Bumetanide | Dehydration, hypotension, low potassium and sodium.[14][3] |
| Angiotensin-Converting Enzyme Inhibitors (ACEIs) | HIGH RISK[14] | Lisinopril, Ramipril (note: –opril suffix) | Reliant on kidney elimination; can accumulate and contribute to renal impairment and dehydration.[14] |
| Angiotensin Receptor Blockers (ARBs) | MODERATE RISK[3] | Losartan (note: –sartan suffix) | Hypotension.[14][3] |
| Beta Blockers | HIGH RISK[14] | Atenolol, Propranolol, Sotalol | Bradycardia, hypotension, carotid sinus hypersensitivity, vasovagal syndrome.[14] |
| Anti-Anginals | Glyceryl Trinitrate (GTN), Isosorbide Mononitrate | Sudden hypotension.[14] | |
| Calcium Channel Blockers | MODERATE RISK[3] | Amlodipine, Felodipine, Diltiazem, Verapamil | Hypotension, bradycardia.[14][3] |
| Other Antidysrhythmics | Digoxin, Flecainide, Amiodarone | Bradycardia, arrhythmias (irregular heart rhythms).[14] | |
| Acetylcholinesterase Inhibitors (for dementia) | POSSIBLE CAUSES[12] | Rivastigmine, Donepezil, Galantamine | Bradycardia and syncope (a brief loss of consciousness due to reduced blood flow to the brain).[12] |
Prevention
Falls have multitude of reasons for occurring, usually caused by a combination of contributing factors and not a single cause.[4] For effective falls prevention a comprehensive, individualised approach is needed. It should identify and addresses the modifiable and non-modifiable risk factors.[17] Physiotherapists have an important role here within the MDT, in the design and implementation of a falls prevention programmes for older adults.[4]
Of the modifiable risk factors for falls, medications, particularly those classified as falls risk-increasing drugs (FRIDs), represent an important area for clinical review.[9][4] A 2022 systematic review and meta-analysis found that medication review and deprescribing as a combined intervention was associated with fewer falls in older adults.[18] Ii contrast a systematic review of randomised controlled trials found that deprescribing FRIDs alone did not significantly reduce the rate or incidence of falls compared with usual care, and finding the evidence in this area remains limited.[19] These findings highlight that deprescribing is best when used in a broader, multifactorial falls prevention approach.[19][4]
With respect to specific drug classes, the 2023 American Geriatrics Society Beers Criteria recommend that all benzodiazepines be avoided in older adults due to their associated risk of falls, fractures, cognitive impairment, and delirium.[15] Gradual tapering rather than abrupt cessation is advised when withdrawing benzodiazepines after prolonged use.[15]
A comprehensive falls prevention strategy should include:[4][17]
- Monitoring of medication use: dose, timing, type, and total number of medications
- Assessment of individual risk factors including comorbidities, mobility, and cognitive status
- Evaluation of environmental factors in the home and care setting
- Identification of specific movements associated with falls (e.g. reaching, lifting, turning, or walking on uneven surfaces)
- Balance and gait training
- Provision or review of appropriate assistive devices
- Education for the person, family members, and carers regarding falls risk factors and prevention strategies
Falls prevention is vital in supporting older adults to maintain their independence and quality of life.[4] A coordinated, person-centred approach which places the individual's needs, goals, and preferences at the centre of care is the best long term approach.[17]
Key Points
Main Drug Classes Increasing Fall Risk:
- Psychotropic drugs (acting on the brain)[11][10]
- Cardiovascular drugs (affecting heart and circulation)[3]
- Diabetic medications (causing hypoglycemia)
Polypharmacy Impact:
- Defined as >3-4 medications[7]
- Using ≥5 drugs increases fall rate to 21% over 2 years[5]
- Risk increases in dose-response manner with number of psychotropics[11]
High-Risk Medications:
- Sedatives (e.g., Lorazepam, Temazepam) - cause drowsiness, slow reactions, impaired balance
- Sedating antidepressants (e.g., Amitriptyline, Nortriptyline) - orthostatic hypotension, drowsiness
- Antipsychotics (e.g., Haloperidol, Olanzapine) - orthostatic hypotension, slow reflexes
- MAO inhibitors (e.g., Phenelzine, Moclobemide) - severe orthostatic hypotension, double fall rate
- Opiate analgesics (e.g., Codeine, Morphine, Tramadol) - sedation, impaired balance
- Antihypertensives - blood pressure effects
- Anti-epileptics - cerebellar damage, ataxia
- Parkinson's medications - delirium, orthostatic hypotension
- Muscle relaxants (e.g., Baclofen) - reduced muscle tone
Clinical Evidence:
- Psychotropic drugs roughly double fall risk[13]
- Antidepressants most strongly linked to fall injuries; antipsychotics linked to hospitalisation and death[11]
- Stopping psychotropic drugs can reduce falls[18][19]
Physiotherapy Relevance:
- Essential awareness for patient safety
- Important for triage roles
- Consult medical colleagues if concerned about medication regimen[4]
References
- ↑ 1.0 1.1 1.2 Zhao Y, Zhang Y, Chen X, et al. Global, regional, and national burden of falls among older adults: findings from the Global Burden of Disease Study 2021 and projections to 2040. npj Aging. 2025;11:42.
- ↑ Kakara R, Bergen G, Burns E, Stevens M. Nonfatal and Fatal Falls Among Adults Aged ≥65 Years — United States, 2020–2021. MMWR Morbidity and Mortality Weekly Report. 2023;72:938–943.
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 de Vries M, Seppala LJ, Daams JG, et al. Fall-risk-increasing drugs: a systematic review and meta-analysis: I. Cardiovascular drugs. Journal of the American Medical Directors Association. 2018;19(4):371.e1–371.e9.
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 Montero-Odasso M, van der Velde N, Martin FC, et al. World guidelines for falls prevention and management for older adults: a global initiative. Age and Ageing. 2022;51(9):afac205.
- ↑ 5.0 5.1 5.2 Dhalwani NN, Fahami R, Sathanapally H, Seidu S, Davies MJ, Khunti K. Association between polypharmacy and falls in older adults: a longitudinal study from England. BMJ Open. 2017;7(10):e016358.
- ↑ Gnjidic D, Hilmer SN, Blyth FM, et al. Polypharmacy cutoff and outcomes: five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes. Journal of Clinical Epidemiology. 2012;65(9):989–995.
- ↑ 7.0 7.1 Pazan F, Wehling M. Polypharmacy in older adults: a narrative review of definitions, epidemiology and consequences. European Geriatric Medicine. 2021;12(3):443–452.
- ↑ Nguyen TX, Nguyen TN, Nguyen ATL, et al. Global and regional prevalence of polypharmacy and related factors, 1997–2022: an umbrella review. Diabetes and Metabolic Syndrome: Clinical Research and Reviews. 2024;18(4):103011.
- ↑ 9.0 9.1 9.2 Ie K, Chou E, Boyce RD, et al. Fall risk-increasing drugs, polypharmacy, and falls among low-income community-dwelling older adults. Innovation in Aging. 2021;5(1):igab001.
- ↑ 10.0 10.1 10.2 10.3 10.4 De Jong MR, Van der Elst M, Hartholt KA. Drug-related falls in older patients: implicated drugs, consequences, and possible prevention strategies. Therapeutic Advances in Drug Safety. 2013;4(4):147–154.
- ↑ 11.00 11.01 11.02 11.03 11.04 11.05 11.06 11.07 11.08 11.09 11.10 Seppala LJ, Wermelink AMAT, de Vries M, et al. Fall-risk-increasing drugs: a systematic review and meta-analysis: II. Psychotropics. Journal of the American Medical Directors Association. 2018;19(4):371.e11–371.e17.
- ↑ 12.0 12.1 12.2 Seppala LJ, van de Glind EMM, Daams JG, et al. Fall-risk-increasing drugs: a systematic review and meta-analysis: III. Others. Journal of the American Medical Directors Association. 2018;19(4):372.e1–372.e8.
- ↑ 13.0 13.1 Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Archives of Internal Medicine. 2009;169(21):1952–1960.
- ↑ 14.00 14.01 14.02 14.03 14.04 14.05 14.06 14.07 14.08 14.09 14.10 14.11 14.12 14.13 14.14 14.15 14.16 14.17 14.18 14.19 14.20 14.21 14.22 14.23 14.24 14.25 14.26 14.27 14.28 14.29 14.30 14.31 14.32 14.33 14.34 Seppala LJ, Petrovic M, Ryg J, et al. STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk): a Delphi study by the EuGMS Task and Finish Group on Fall-Risk-Increasing Drugs. Age and Ageing. 2021;50(4):1189–1199.
- ↑ 15.0 15.1 15.2 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7):2052–2081.
- ↑ Petriceks AH, Appel LJ, Miller ER, et al. Timing of orthostatic hypotension and its relationship with falls in older adults. Journal of the American Geriatrics Society. 2023;71(12):3711–3720.
- ↑ 17.0 17.1 17.2 Pillay J, Gaudet LA, Saba S, et al. Falls prevention interventions for community-dwelling older adults: systematic review and meta-analysis of benefits, harms, and patient values and preferences. Systematic Reviews. 2024;13:289.
- ↑ 18.0 18.1 Seppala LJ, Kamkar N, van Poelgeest EP, et al. Medication reviews and deprescribing as a single intervention in falls prevention: a systematic review and meta-analysis. Age and Ageing. 2022;51(9):afac191.
- ↑ 19.0 19.1 19.2 Page AT, Clifford RM, Potter K, Schwartz D, Etherton-Beer CD. Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall-related complications: a systematic review and meta-analysis. BMJ Open. 2021;11(2):e035978.