Lowering The Risk of Falls

Looking at these drugs you will most likely identify several that you pass to residents on a daily basis. Knowing which ones carry a high risk for falls is the first step in protecting residents. 
Any medication acting on the brain (psychotropics) or affecting cardiovascular function can increase fall risk. Psychotropics including anxiolytics/sedative-hypnotics, antipsychotics, antidepressants, anticonvulsants, and narcotic pain medications typically increase risk due to their effects on cognitive function, resulting in sedation, slower reaction times, and impaired balance. Cardiovascular medications often either lower blood pressure with subsequent hypotension or affect heart rate, resulting in bradycardia, tachycardia, or periods of asystole.

Psychotropic Drugs

Anxiolytics/Sedative-Hypnotics
Benzodiazepines are used for their antianxiety and sedative/hypnotic properties and include diazepam (Valium), clonazepam, alprazolam (Xanax), lorazepam (Ativan), and temazepam. Nonbenzodiazepine hypnotics or Z-hypnotics have a similar side effect profile to that of benzodiazepines and include zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata).

Benzodiazepines  use continues to be widespread despite numerous guidelines recommending against it in older adults due to the risk of cognitive impairment, unsteady gait, psychomotor impairment, accidents, delirium, and dependence, which develops quickly. Most studies show a significant association between benzodiazepines and Z-hypnotic use and falls or fractures.

Antipsychotics
Antipsychotic medications, including haloperidol (Haldol), olanzapine (Zyprexa), quetiapine (Seroquel), aripiprazole (Abilify), and risperidone (Risperdal), can increase fall risk due to syncope (fainting), sedation, slowed reflexes, loss of balance, and impaired psychomotor function.

Antidepressant
Hyponatremia and Fall Risk
It is important to note that most antidepressants, with the likely exception of bupropion (Wellbutrin), can cause hyponatremia (low sodium levels), an independent risk factor for falls in older adults. 

Sedating Antidepressants
Tricyclic antidepressants (TCAs) should be avoided in older adults due to their side effect profiles. Anticholinergic side effects of TCAs include confusion, cognitive impairment, delirium, dry mouth, constipation, and urinary retention. All have some alpha-blocking activity and can cause orthostatic hypotension. Their antihistamine properties can cause sedation, impair balance, and slow reaction times. Common TCAs include amoxapine, desipramine (Norpramin), doxepin, imipramine (Tofranil), and nortriptyline (Pamelor). 

Common antidepressants, including mirtazapine (Remeron) and trazadone, which have chemical structures similar to TCAs but different overall side effect profiles, can also increase fall risk.

Selective Serotonin Reuptake Inhibitors (SSRIs)
Common SSRI antidepressants include citalopram (Celexa), escitalopram (Lexapro), sertraline (Zoloft), paroxetine (Paxil), and fluoxetine (Prozac). SSRIs can cause ataxia (loss of coordination), impaired psychomotor function, and syncope (fainting), contributing to increased fall risk.

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
Side effects for SNRI antidepressants are similar to those associated with SSRIs; however, these also commonly cause orthostatic hypotension.

Anticholinergic Medications and Side Effects
Any medication with anticholinergic properties should be used with caution in older adults and avoided when possible. Anticholinergic effects can increase confusion, cognitive impairment, delirium, dry mouth, and constipation and cause urinary retention (the 4 great I can'ts). Of the medications noted, olanzapine, paroxetine, and TCAs all possess significant anticholinergic side effects.

Sedating antihistamines are anticholinergic medications and should be avoided in older adults. These include bropheniramine, chlorpheniramine, cyproheptadine, diphenhydramine (Benedryl), doxylamine, and hydroxyzine.

Cardiovascular Drugs
Any drug that reduces blood pressure or slows the heart may cause falls, faint feelings, loss of consciousness, or "legs giving way," especially in cases of polypharmacy.

Cardiovascular drugs generally contribute to falls as a result of hypotension (low blood pressure), orthostatic hypotension (sudden drop in blood pressure upon standing), syncope (fainting), or presyncope (state of lightheadedness, muscular weakness, blurred vision, and feeling faint from carotid sinus hypersensitivity or vasovagal syncope).

Diuretics
Diuretics can cause orthostatic hypotension, and hypotension risk is increased with dehydration. They also may cause weakness due to potassium loss as well as hyponatremia.

Pain Medications
Studies looking at fall risk associated with opioid pain medications have been inconsistent; however, a number of studies have demonstrated a strong link between opioid use and increased fall risk. Common opioids include morphine, hydromorphone, fentanyl, oxycodone, and also the opioidlike drug tramadol (Ultram). Opioids can cause sedation, dizziness, syncope, and central nervous system depression.

A recent study found recent opioid use to be associated with an increased risk of falls and an increased risk of death in older adults.  Patients whose falls were linked to opioid use were also more likely to die during their hospital stay.

Anticonvulsants
All anticonvulsants including gabapentin (Neurontin), levetiracetam, phenytoin, and valproate increase fall risk. Side effects contributing to fall risk include ataxia, impaired psychomotor function, and syncope (fainting).