Medication Safety & Fall Risk

40%

of falls in older adults involve medications as a contributing factor

prescription medications taken daily = "polypharmacy" — a defined fall risk factor

57%

reduction in falls shown in studies where fall-risk medications were deprescribed

Why medications matter for fall risk

Many medications that are appropriate and necessary for treating one condition have side effects — dizziness, sedation, orthostatic hypotension, impaired coordination — that directly increase fall risk. This is not a reason to stop taking your medications. It is a reason to have an informed conversation with your doctor and pharmacist about whether there are alternatives, lower doses, or better timing strategies that reduce the risk while maintaining treatment effectiveness.

The key tool for this conversation is the Beers Criteria — a regularly updated list published by the American Geriatrics Society identifying medications that are potentially inappropriate for older adults.

High Fall-Risk Drug Categories

bedtime

warningVery High Risk

Sedatives & Sleep Aids

Benzodiazepines (Valium, Xanax, Ativan, Klonopin), non-benzodiazepine sleep aids (Ambien/zolpidem, Lunesta/eszopiclone), and Z-drugs are among the highest-risk medications for falls. They impair balance, reaction time, and coordination — effects that persist into the next morning.

Mechanisms:

Sedation Impaired balance Slowed reaction time Morning hangover effect

On Beers Criteria: Yes — explicitly listed. Safer alternatives include cognitive behavioral therapy for insomnia (CBT-I), melatonin, and improved sleep hygiene practices.

monitor_heart

warningHigh Risk

Blood Pressure Medications

Antihypertensives — including beta-blockers, ACE inhibitors, calcium channel blockers, and diuretics — can cause orthostatic hypotension: a sudden drop in blood pressure when standing up. This causes dizziness and lightheadedness that can lead to a fall in the first few seconds of standing.

Mechanisms:

Orthostatic hypotension Dizziness on standing Dehydration (diuretics)

Strategy: Rise slowly from bed or a chair. Sit on the edge for 30 seconds before fully standing. Tell your doctor if you feel dizzy when standing up — dose adjustment or timing changes can help.

psychology

warningModerate–High Risk

Antidepressants

Both older antidepressants (tricyclics like amitriptyline) and newer ones (SSRIs like sertraline/Zoloft, fluoxetine/Prozac) are associated with increased fall risk. SSRIs affect sodium balance and impair blood pressure regulation. Tricyclics have additional anticholinergic effects that cause sedation and confusion.

Mechanisms:

Orthostatic hypotension Sedation (TCAs) Hyponatremia (SSRIs) Anticholinergic effects

On Beers Criteria: Tricyclics explicitly listed. SSRIs noted as increasing fall and fracture risk. Do not stop antidepressants without medical supervision — the depression itself also increases fall risk.

sick

warningModerate Risk — Often Overlooked

Antihistamines (Allergy & Sleep)

Diphenhydramine (Benadryl, ZzzQuil, Tylenol PM, Advil PM) is one of the most dangerous medications for older adults — yet it's sold over the counter and perceived as safe. It crosses the blood-brain barrier easily, causing sedation, confusion, blurred vision, and urinary retention — all fall risk factors.

Mechanisms:

Sedation Confusion / delirium Blurred vision Strong anticholinergic

On Beers Criteria: Explicitly listed — should be avoided in older adults. Safer alternatives for allergies: loratadine (Claritin) or cetirizine (Zyrtec). For sleep: see sleep aids section above.

water_drop

warningModerate Risk

Diuretics ("Water Pills")

Loop diuretics (furosemide/Lasix) and thiazides (hydrochlorothiazide) cause increased urination, which can lead to dehydration, electrolyte imbalances (especially low sodium and potassium), and orthostatic hypotension. Urgency to reach the bathroom quickly — particularly at night — is itself a fall risk.

Mechanisms:

Orthostatic hypotension Dehydration Electrolyte imbalance Nighttime urgency

Strategy: Take morning doses early so peak effect is during daylight. Maintain good hydration. A bedside commode or urinal can eliminate nighttime trips to the bathroom.

glucose

warningModerate–High Risk

Diabetes Medications

Insulin and sulfonylureas (glipizide, glyburide, glimepiride) can cause hypoglycemia — dangerously low blood sugar — which produces sudden dizziness, weakness, shakiness, and confusion. A hypoglycemic episode while standing, walking, or navigating stairs can result in a serious fall.

Mechanisms:

Hypoglycemia Sudden dizziness Cognitive impairment Weakness

Strategy: Know your hypoglycemia warning signs. Carry glucose tablets. If you have a CGM (continuous glucose monitor), set low alerts. Discuss tighter glucose management vs. hypoglycemia risk with your endocrinologist.

menu_book

The Beers Criteria

The Beers Criteria is a list of medications that the American Geriatrics Society (AGS) considers potentially inappropriate for adults age 65 and older. It is updated every three years based on the latest evidence. The list includes drugs that should be avoided entirely, drugs that require dose adjustment in older adults, and drugs with significant drug-drug interactions common in this population.

The Beers Criteria is not a prescription for stopping medications. It is a structured framework for a conversation with your doctor about whether the benefits of a medication still outweigh its risks given your current health status, age, and fall risk profile.

What the Beers list includes

checkSedatives and sleep aids (benzodiazepines, Z-drugs)
checkAnticholinergic drugs (diphenhydramine, oxybutynin, tolterodine)
checkAntipsychotics (haloperidol, quetiapine, risperidone)
checkTricyclic antidepressants (amitriptyline, nortriptyline)
checkSkeletal muscle relaxants (cyclobenzaprine, methocarbamol)
checkCertain pain medications (meperidine, indomethacin)

How to use it

1.Bring a complete list of ALL medications — prescription and OTC — to your next appointment.
2.Ask your pharmacist or doctor: "Can you review my medications using the Beers Criteria for fall risk?"
3.For any flagged medication, ask: "Is there a safer alternative? Can we reduce the dose? Can we change the timing?"
4.Never stop a medication without medical supervision.

5 Questions to Ask Your Pharmacist

Print this list and bring it to your next pharmacy visit. Most pharmacists welcome this conversation and many offer free Medication Therapy Management (MTM) reviews for Medicare patients.

"Do any of my medications increase my fall risk?"

Ask this of all your medications — prescription and over-the-counter. Bring the actual bottles, not just a list.

"Am I eligible for a free Medication Therapy Management review under Medicare?"

Medicare Part D plans are required to offer MTM to high-risk beneficiaries. This is a comprehensive review by a pharmacist — completely separate from your doctor visit.

"Is Benadryl or diphenhydramine in any of my over-the-counter medications?"

Diphenhydramine is hidden in many branded products: Tylenol PM, Advil PM, ZzzQuil, Unisom SleepTabs, many cold and allergy medications. Ask specifically.

"Could the timing of when I take these medications reduce my fall risk?"

Taking a sedating medication at night rather than morning, or a diuretic in the morning rather than evening, can meaningfully reduce the risk window without changing the medication itself.

"Are there any drug interactions in my current regimen that could cause dizziness or balance problems?"

When multiple medications are combined, the interaction can produce fall-risk side effects that neither drug causes alone. This requires a full medication list to evaluate properly.

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