Medications and Falls in the Elderly:

A Review of the Evidence and

Practical Considerations
Elsaris Z. Riefkohl, PharmD, Heather L. Bieber, PharmD, Mark B. Burlingame, PharmD, BCPS,
and David T. Lowenthal, MD, PhD

ABSTRACT
The syndrome of falls is a common and an often serious
problem in elderly people. The cause of falls is multifactorial,
and medication use can be a significant contributor. The
observational nature of the research in this field makes it
difficult to draw conclusions regarding medication use and falls
in clinical practice, although psychotropic drugs appear to be
most strongly associated with falls. Medication assessment is
an important part of evaluating elderly patients at risk for
falling.

In this article, we discuss the published evidence examining the relationship between medication use and falls to provide a practical approach to the clinical evaluation of drug
therapy in elderly patients at risk for falling.

MEDICATIONS AND THE RISK OF FALLS

Some of the intended and unintended pharmacological
effects of drug therapy (e.g., sedation, psychomotor impairment, cognitive changes, dizziness, and orthostatic hypotension) might be expected to increase the risk of falls.
Numerous published studies have sought to establish an
association between medication use and risk of falling.

INTRODUCTION

Meta-analyses

Falling is a common health problem for institutionalized

and community-dwelling elderly people and is a significant
contributor to morbidity and mortality. A review of prospective
studies of community-based elderly populations reports an
annual mean of 34% (range, 30%60%) of older adults who fall,
with a mean incidence rate of 0.7 falls per person per year.1 For
institutionalized elderly people, the same review reports an
annual mean of 43% (range, 16%75%) of residents who fall, with
an incidence rate of 1.6 falls per person per year in long-term
care facilities and 1.4 falls per resident per year in hospitalized
elderly patients. The rate of falls also rises with advancing
age.2
Although most falls in older adults do not result in severe
injury, 5% to 10% of falls do result in a serious outcome, such
as fracture, head injury, or laceration.1 Furthermore, accidents are the fifth leading cause of death in older people, with
falls contributing to two thirds of these deaths.1 Among people who fall and have fractures, those with hip fracture face the
most serious consequences; approximately 20% of victims die
within a year, and another 20% are institutionalized for the first
time.3
The cause of falling can vary, and many risk factors have
been identified. One risk factor is the use of certain types of
medications, especially when used in combination. Published
guidelines recommend a medication review as part of a comprehensive approach to the prevention of falls in the elderly.4,5

Leipzig et al. published two meta-analyses in 1999 in an

attempt to clarify some of the issues surrounding medication
use and falls.6,7 In the first study, the authors identified 40
trials, between 1966 and 1996, that evaluated the association
between the use of sedative/hypnotic agents, antidepressants,
neuroleptics, and psychotropic drugs and the risk of falls in
people who were 60 years of age and older.6 None of the studies was a randomized, controlled trial, which is a significant
limitation in the literature on this topic. When the authors
analyzed the pooled data and calculated the odds ratios, they
found a significant relationship between the use of psychotropic drugsas a group as well as for the various classes of
psychotropic drugsand one or more falls.
In the second study, the authors identified 29 trials, in the
same time period, that evaluated the association between the
use of several classes of cardiovascular or analgesic drugs
and falls in people 60 years of age and older.7 Again, none of
these studies was a randomized, controlled trial. The authors
found a significant relationship between the risk of falls and the
use of type-IA antiarrhythmic agents, digoxin, and diuretics
only but not between falls and angiotensin-converting enzyme
inhibitors, calcium-channel blockers, beta blockers, centrally
acting antihypertensive agents, and nitrates. No significant
association was found between the use of any of the analgesic
drug classes analyzed and the risk of falls.
According to these results of the meta-analyses, psychotropic drugs had the strongest association with falls, with
cardiac and analgesic drugs having little or no correlation. The
authors also found that patients using three or more medications appeared to be at an increased risk for recurrent falls.6,7

Dr. Riefkohl and Dr. Bieber are Clinical Pharmacists and Dr.
Burlingame is Clinical and Education Program Manager at the North
Florida/South Georgia Veterans Health System in Gainesville, Florida.
Dr. Lowenthal is Director Emeritus of the Geriatric Research, Education, and Clinical Center at the North Florida/South Georgia Veterans
Health System and Professor of Medicine, Pharmacology, and Exercise
Science at the University of Floridas College of Medicine in Gainesville.

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Benzodiazepines
Because of the potential for prolonged central nervous system side effects, it is generally recommended that long-acting
benzodiazepines be avoided in older people. Therefore, one

Medications and Falls in the Elderly

might assume that the use of these agents would pose a greater
risk of falling than would the use of the short-acting benzodiazepines. However, results of studies that examined falls
and both types of benzodiazepines have been variable.
Ray et al. studied nursing-home residents in order to quantify the rate of falls among those who took benzodiazepines and
to see the variations with regard to the elimination half-lives
of the drugs.8 Current benzodiazepine users experienced a rate
of falls that was 44% greater than the rate for non-users. In
cohort members for whom benzodiazepine use was new, the
rate of falls was greatest in the first seven days after the initial
therapy and remained elevated after the first 30 days of therapy. The rate of falls increased with longer elimination halflives, although users of very-short-acting benzodiazepines
(less than 12 hours) experienced an increased rate of falls
during the night but not during the day.
Some studies of hospitalized patients have suggested that a
greater risk of falling is associated with the use of short-acting
benzodiazepines than with long-acting benzodiazepines. In
one of these studies, patients taking lorazepam (Ativan,
Wyeth-Ayerst) and alprazolam (Xanax, Pharmacia) had a
higher rate of falls per dose dispensed than those taking
diazepam (Valium, Roche).9 In another study of hospitalized
patients, the use of short-acting and very-short-acting benzodiazepines was positively associated with falls, whereas the use
of long-acting benzodiazepines was not.10
Ensrud et al., conducting a prospective, multicenter cohort
study in community-dwelling women 65 years of age and older,
concluded that the use of both short-acting and long-acting
benzodiazepines was associated with frequent falls, compared
with the rate for those not taking these drugs; however, the
confidence interval (CI) for both classes of benzodiazepines
overlapped (1.0).11
Studies examining exposure to benzodiazepines and the
risk of hip fracturerather than the risk of fallshave suggested that short-acting benzodiazepines do not confer a safety
advantage over long-acting benzodiazepines.12,13 One of these
studies also indicated an increased fracture risk for those taking higher doses of all benzodiazepines as well as a greater risk
for patients in the early stages of their benzodiazepine therapy
and also for patients who have taken benzodiazepines for
longer than a month.13
On the basis of these results, it is difficult to make practice
decisions about the risk of falling and the relationship to longacting versus short-acting benzodiazepines. Perhaps clinicians
should weigh the advantages and disadvantages of all categories of benzodiazepines when making treatment decisions
for elderly people at risk for falls.

Antidepressants
Because the use of selective serotonin reuptake inhibitors
(SSRIs) is generally preferable to the use of tricyclic antidepressants (TCAs) in older patients, one might postulate that
SSRIs are associated with a reduced risk of falls compared with
TCAs. However, published data examining different classes of
antidepressants and falls indicate that older people who use
SSRIs might not be any safer than those who use TCAs.
Two studies, one in the nursing-home setting and the other
in the community setting, suggest a higher risk of falls for users

of SSRIs than for users of TCAs.11,14 Another nursing-home

study documented a significantly greater rate of falls in users
of both TCAs and SSRIs.15 Furthermore, the fall rate increased
with increasing doses for each class of antidepressant. These
data suggest that elderly people who begin therapy with any
antidepressant should be considered at risk for falling.

Antihypertensive Drugs
Antihypertensive agents as a class also receive a great deal
of attention from clinicians who evaluate patients at risk for
falls. Some practitioners are concerned that the blood pressurelowering effects of these drugs might contribute to orthostasis and dizziness. Of course, acute treatment of hypertension can result in orthostatic hypotension through several
mechanisms; however, chronic therapy is rarely associated
with orthostasis. In fact, it is possible that antihypertensive
drugs might improve the cerebral and systemic vascular
responses to hypotensive stress and may reduce postprandial
declines in blood pressure.16 Furthermore, an increased risk
of falls has not been associated with the use of antihypertensive drugs.7,1719
So far, it appears that the use of chronic antihypertensive
therapy should not be a major concern, although individual
cases of documented antihypertensive-induced orthostasis
should not be ignored.

Anticonvulsants
The results of the prospective cohort study in elderly women
by Ensrud et al. (see the earlier discussion of benzodiazepines
and antidepressants), also noted a significantly greater risk of
falls in patients using anticonvulsant agents.11 The authors
concluded that community-dwelling elderly women who were
using medications that affect the central ner vous system
experienced an increased risk of falling; however, narcotic
use was not associated with an increased risk.

Summary of Evidence
Although the varied results from the research make it difficult to derive conclusions regarding medications and falls in
the elderly, we can generalize as follows:
1. Psychotropic agents are associated with an increased risk
of falling, and caution is warranted with all of these drugs.
Anticonvulsants, class IA antiarrhythmics, and digoxin
(e.g., Digitek, Bertek; Lanoxin, GlaxoSmithKline)
might also be associated with an increased risk of falls.
2. The chronic use of antihypertensive drugs is probably not
associated with an increased risk of falls.
3. Potentially important pharmacotherapeutic factors, other
than the drug or the drug class, include the use of multiple medications and the dosages taken.

INTERVENTION STUDIES
Most intervention studies on falls provide limited or no
details about the medications taken by the study population.
Perhaps one of the best-known studies in which a medication
review was specifically identified as part of a multifaceted
intervention was a trial conducted by Tinetti and colleagues in
a community-based population.20 In this study, sedatives were

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Medications and Falls in the Elderly

withdrawn and the number of medications was decreased.
The intervention group demonstrated a relative risk reduction
of 31% for falls.
Other studies targeting the reduced use of psychotropic,2123
cardiovascular,23,24 and analgesic drugs23 have also reported
success in decreasing the risk of falls in older people. We
reported the use of medications as a major contributing factor
to the risk of falling in 25% of patients evaluated in our falls
clinic; the most frequent recommendations about medication
use involved the class of psychotropic drugs.25

PRACTICAL CONSIDERATIONS
To evaluate the medication regimens of older patients who
might be at risk for falls, clinicians should combine an evidence-based approach with a knowledge of the potential effects
of drug therapy. The evaluation should also be performed in
the context of:26

the patients history of falls.

an appropriate laboratory assessment.
a gait and balance assessment.
a comprehensive physical evaluation, including:
a vision examination.
a measurement of postural blood pressure.
a targeted neurologic, musculoskeletal, and
cardiovascular examination.

Medication History
Before a medication regimen can be assessed, clinicians
must have an accurate listing of all drugs used. Therefore, a
vitally important aspect of the medication evaluation is the
medication history.
Patients in the community setting often take prescribed
drugs in a way that differs from the instructions that are listed
in the medication profile in the medical record. It is helpful
when ambulatory patients bring their medications with them
to clinic visits.
Clinicians should take care to ask patients about over-thecounter drugs and herbal products they are taking, because
patients do not always think of these as medications.
Clinicans should also ask about adverse reactions to previous medications and about perceived side effects of their
current prescriptions.
Inquiring about alcohol consumption is also important,
because alcohol can contribute to the risk of falls.
As part of the medication history, physicians should ask
patients whether certain drugs, particularly analgesics, have
been effective in alleviating their symptoms. In our experience,
many patients who have used drugs such as propoxyphene
(e.g., Darvon, NeoSan) and gabapentin (Neurontin, Pfizer)
for pain report minimal or no positive effects, but they continue
to take such medications because a health care provider has
prescribed them. Furthermore, ineffective analgesia may
inhibit patient par ticipation in any prescribed physical
rehabilitation programs, such as balance and strength-training
exercises.

Minimizing the Use of Drugs Associated with the Risk

of Falls
Published practice guidelines recommend the following:
Patients who have fallen should have their medications
reviewed and altered or stopped as appropriate in light of their
risk of future falls. Particular attention to medication reduction should be given to older persons taking four or more
medications and to those taking psychotropic drugs.4

Although psychotropic drugs (e.g., benzodiazepines, antidepressants, antipsychotic agents) may be the initial focus of
a medication review, other drugs and drug classes may have
intended or unintended pharmacological effects that can
increase the risk of falling and thus might also be considered
high risk in some cases.
Table 1 lists drugs and drug classes for clinicians to consider
when they are assessing drug regimens in patients at risk for
falls. Others to be targeted for elimination or a reduction in
dose include the following:

drugs that are ineffective

drugs that are thought to be causing adverse effects
drugs for which a therapeutic duplication might exist
drugs for which an indication is not known or
documented
drugs for which the dose seems to be high for an older
person

Table 1

Drugs and Drug Classes to Consider

in Evaluating Elderly Patients with
an Increased Risk of Falling*

Antidepressants
Antipsychotics
Benzodiazepines
Antihypertensives
Antihistamines
Anticonvulsants
Nonsteroidal anti-inflammatory drugs
Corticosteroids
Muscle relaxants
Narcotic analgesics
Antiarrhythmics (type IA)
Digoxin
Nitrates
Hypoglycemics
Antiparkinson drugs
Histamine H2-receptor blockers
* Not all drugs and drug classes listed have been associated with falls
in published research.Therefore, this list should be used in the context
of a comprehensive clinical assessment for each individual patient.
Published research suggests an association between the use of this
drug or drug class and an increased risk of falling.
Includes selective serotonin reuptake inhibitors (SSRIs).
Especially sedating antihistamines, such as diphenhydramine HCl
(e.g., Benadryl, Pfizer) and hydroxyzine (e.g.,Atarax, Pfizer).
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Assessing Patients for Untreated Conditions

In the overall patient assessment, clinicians should consider
instituting drug therapy when it might help to improve functional status, as in patients with untreated or poorly controlled
conditions, including Parkinsons disease, benign prostatic
hyperplasia, pain, and depression.
Deficiencies of some vitamins (e.g., B1227 and D28) and
hormones (e.g., testosterone deficiency in males29 and hypothyroidism30) are more common in elderly people and may
contribute to symptoms that interfere with functional status.
Clinicians should consider screening for vitamin deficiencies,
and supplementation may be needed in selected individuals.
Patients with osteopenia and osteoporosis should receive
calcium and vitamin D as well as anti-resorption drugs when
necessary.

10.
11.
12.
13.
14.
15.

SUMMARY

16.

Falling is a common health problem in the elderly population. The use of medications is one of the many different factors that can contribute to balance problems and the risk of
falls. Clinicians should make decisions about drug therapy
based upon published research about falls and a knowledge of
desirable and undesirable drug effects. Integral practice-based
components of medication assessment include taking the
patients medication history, minimizing the use of high-risk
drugs, and managing uncontrolled diseases and disorders. A
thorough assessment of medication regimens and skillful medication management can reduce the risk of falls in elderly
people.

17.
18.
19.
20.
21.
22.

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