Medications and Their Impact on Fall Risk

Emmanuel Osei-Boamah, M.D., is a primary care physician with Mercy Family Care in Baltimore, Maryland. Double board certified in geriatric and internal medicine, Dr. Osei-Boamah has more than 30 years of experience in clinical healthcare. Recently, Dr. Osei-Boamah responded to questions posed by HealthCentral.com regarding medications and the increased risk of falls. Dr. Osei-Boamah examined which medications may increase fall risk and how best to reduce that risk. 

Which medications may increase a patient’s risk of falls?

Multiple medication classes increase fall risk in older adults, with the strongest evidence for psychotropic medications (benzodiazepines, antidepressants, antipsychotics, sedative-hypnotics), opioids, and certain cardiovascular agents.

Psychotropic medications
Benzodiazepines and sedative-hypnotics are among the highest-risk medications, with benzodiazepines showing an odds ratio (OR) of 1.76 for head injuries and hypnotics-sedatives showing an OR of 1.90 for falls in hospitalized patients. Z-drugs (zaleplon, zolpidem) demonstrate particularly strong associations with head injuries (OR 3.09). These medications impair postural control through sedation and are more problematic at higher doses, with longer half-lives, and with prolonged use. 

Antidepressants consistently increase fall risk across multiple classes, including tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs). Hospitalized patients taking antidepressants show an OR of 2.25 for falls. 

Antipsychotics are associated with increased fall risk (OR 1.61-2.75), with particularly strong associations for fall-related head injuries.

Analgesics
Opioids substantially increase fall risk (OR 1.23-1.60), with the highest risk occurring at initiation. The combination of opioids with gabapentinoids (gabapentin, pregabalin) further amplifies fall risk. 

NSAIDs are associated with falls requiring medical treatment, likely due to increased bleeding risk rather than direct effects on balance.

Cardiovascular medications
Loop diuretics show the greatest fall risk among cardiovascular medications, particularly within 30 days of initiation.  Other cardiovascular agents associated with falls include β-blockers, α-blockers, and angiotensin II antagonists, primarily through orthostatic hypotension. 

Other high-risk medications
Anticholinergic medications (including antihistamines like diphenhydramine, overactive bladder medications, and muscle relaxants) increase fall risk through sedation, dizziness, and impaired cognition.  Medications with an anticholinergic burden score of 3 increase fall risk by more than 50%.

Anti-Parkinson agents (OR 1.30-1.58) and antiepileptics (OR 1.19-1.55) are consistently associated with increased falls. 

Polypharmacy (≥4-5 medications) independently increases fall risk (OR 1.75), with patients taking ≥10 medications showing 50% higher fall rates.  The American Geriatrics Society Beers Criteria recommend using anticholinergics, antidepressants, antiepileptics, antipsychotics, benzodiazepines, and opioids with caution in older adults with fall history. 

Why do these medications increase falling risk?

Polypharmacy substantially increases fall risk in elderly patients through a dose-response relationship, with risk escalating even at lower medication counts and persisting after adjustment for comorbidities and specific fall-risk-increasing drugs (FRIDs).

Definition and prevalence
Polypharmacy is typically defined as concurrent use of 5 or more medications, while excessive polypharmacy refers to use of more than 10 medications.  Prevalence reaches approximately 47-51% among community-dwelling older adults and is even higher in long-term care settings. 

Mechanisms of increased fall risk
Polypharmacy increases fall risk through multiple pathways: cumulative side effects including sedation, dizziness, orthostatic hypotension, and impaired cognition; drug-drug interactions; and increased likelihood of exposure to FRIDs.  Gait disturbances mediate the relationship between medication number and falls—specifically, impairments in stride length, step length, and step width explain part of the association between polypharmacy and fall incidence.  The American Heart Association notes that medications affecting the central nervous system, causing anticholinergic effects, or impairing vision and balance contribute to abnormal gait and poor postural control. 

Quantified risk
The fall rate demonstrates a clear dose-response pattern: 0.84 falls per person-year with no polypharmacy, 1.13 with polypharmacy (5-10 medications), and 1.84 with excessive polypharmacy (>10 medications). Each additional medication increases gait decline risk by 12-16% and fall incidence risk by 5-7%. 

Hospital admission risk due to falls increases substantially with polypharmacy: fully adjusted hazard ratios are 1.75 (95% CI 1.04-2.95) for polypharmacy and 3.19 (95% CI 1.61-6.32) for excessive polypharmacy compared to no medications. Even after controlling for comorbidities and FRIDs, using 10 or more medications confers an almost two-fold higher risk of fall injury (adjusted OR 1.76, 95% CI 1.66-1.88). Patients with polypharmacy experience a 50% higher fall rate than those without polypharmacy. 

Persistent polypharmacy (maintaining ≥6 medications over consecutive visits) increases fall injury risk by 31% (HR 1.31, 95% CI 1.06-1.63), with the highest risk when combined with FRID use (HR 1.48, 95% CI 1.10-2.00). 

Role of specific medications
The American Geriatrics Society Beers Criteria identify high-risk medications that should be used with caution in older adults with fall history, including anticholinergics, antidepressants, antiepileptics, antipsychotics, benzodiazepines, and opioids.  Anticholinergic burden significantly amplifies risk—medications with an anticholinergic burden score of 3 increase fall risk by more than 50%.  Among cardiovascular medications, loop diuretics show the greatest fall association, particularly within 30 days of initiation. 

Opioid and anticholinergic medication use independently predict fall incidence in long-term care (incidence rate ratios of 1.73 and 1.48, respectively). The combination of polypharmacy with potentially inappropriate medications (PIMs) per Beers Criteria shows particularly strong associations with fall risk. 

Clinical recommendations
Regular medication review and deprescribing are essential fall prevention strategies. The American College of Surgeons recommends carefully reviewing medication history and limiting high-risk medications as well as total medication count. Evidence supports that reducing psychotropic medications significantly decreases geriatric falls.  The American Heart Association emphasizes minimizing drug index burden (total exposure to anticholinergic and sedative medications). Prescriptions should be revised regularly to keep medication numbers to a minimum, reducing fall-related hospital admissions.

What steps can be taken to reduce fall risk?

Reducing fall risk in elderly patients with polypharmacy requires a multifaceted approach centered on structured medication review, exercise interventions, and multifactorial risk assessment tailored to individual patient needs.

Fall risk assessment and screening
Annual screening for fall risk is recommended for all adults aged 65 and older, not just those with a history of falls. The American Geriatrics Society recommends performing gait and balance assessment for all older adults who screen positive for fall risk, preferably using the Timed Up and Go (TUG), 30-second chair stand, or 4-stage balance test.  Gait speed has the best evidence to predict future fall risk, though the TUG may better identify multiple mobility impairments that guide interventions. High-risk features include multiple falls (≥2) in the prior year, fall-related injury, frailty, gait speed <0.8-1 m/s, or inability to get up without assistance within an hour after a fall. 

Medication review and deprescribing
Structured medication review using validated tools is essential for identifying and reducing fall-risk-increasing drugs (FRIDs).  The American Geriatrics Society recommends using tools such as STOPPFall, Beers Criteria, or the CDC SAFE Medication Review Framework to systematically identify FRIDs. Fall history and risk should be assessed before prescribing FRIDs, with particular attention to psychotropic medications, benzodiazepines, opioids, anticholinergics, and antihypertensives.

Evidence supports significant decreases in geriatric falls when psychotropic medications are eliminated. All prescribed and over-the-counter drugs should be reviewed, with focus on tapering or discontinuing medications without compelling indication, particularly those causing sedation, confusion, or orthostatic hypotension (antidepressants, antipsychotics, benzodiazepine-receptor agonists, antiepileptic drugs, opioids, antihypertensive agents). Deprescribing should consider patient-specific factors including frailty status, life expectancy, patient goals of care, and preferences, with emphasis on patient monitoring, support, and documentation. 

Exercise and physical therapy
Exercise interventions demonstrate the strongest evidence for fall prevention, with meta-analysis showing 655 falls per 1000 patient-years in exercise groups versus 850 falls per 1000 patient-years in control groups (rate ratio 0.77; 95% CI, 0.71-0.83). Effective interventions include supervised individual physical therapy and group exercise classes, with most common components being gait, balance, and functional training, followed by strength and resistance training. Tai chi and other 3-dimensional exercises that involve movement through all spatial planes are particularly effective.

The most common frequency and duration is 2-3 sessions per week for 12 months, though duration ranges from 2-30 months. Exercise interventions should be tailored to individual risk and mobility, as exercise may increase fall risk in some individuals who become more mobile as their strength increases. 

Additional multifactorial interventions
Multifactorial interventions based on systematic clinical assessment reduce fall rates among high-risk populations (1784 falls per 1000 patient-years versus 2317 in controls; rate ratio 0.77; 95% CI, 0.67-0.87). Components should include:

• Vision assessment and treatment: Cataract surgery is associated with reduced falls (risk ratio 0.68; 95% CI, 0.48-0.96) 
• Environmental modifications: Effective for high-risk patients (risk ratio 0.74; 95% CI, 0.61-0.91), including home-safety evaluation and adaptive equipment 
• Cardiovascular assessment: Including orthostatic blood pressure measurement and management of postural hypotension 
• Multicomponent podiatry interventions: Associated with reduced falls (risk ratio 0.77; 95% CI, 0.61-0.99)
• Vitamin D supplementation: Recommended as part of multifactorial interventions 

The combination of exercise and vision assessment and treatment appears most strongly associated with reduction in injurious falls. Multifactorial assessment should include balance, gait, vision, postural blood pressure, medication, environment, cognition, and psychological health, with subsequent customized interventions based on identified issues. 

Implementation considerations
Healthcare providers should carefully review medication history and limit high-risk medications as well as total medication count. Polypharmacy (≥5 medications) should be avoided whenever possible, as patients with polypharmacy have a 21% higher fall rate, and those taking ≥10 medications have a 50% higher rate than those without polypharmacy. Fall prevention is reimbursed as part of the Medicare Annual Wellness Visit. Patient and caregiver education about fall risks, particularly those associated with polypharmacy and certain medications, is essential. 

– Emmanuel Osei-Boamah, M.D.

Dr. Emmanuel Osei-Boamah earned his medical degree from the School of Medical Sciences, Kwame Nkrumah University of Science and Technology, in Kumaski, Ghana, completing his internal medicine residency at St. Agnes Healthcare in Baltimore, Maryland, and his fellowship in Geriatric Medicine at the University of Maryland School of Medicine. He is a member of the American College of Physicians, the American Medical Association, the American Geriatric Society and the American Medical Directors Association.