Medicines Associated with Falls

Fall-risk-increasing drugs are medicines that raise the chance of a fall through sedation, postural hypotension, bradycardia, hypoglycaemia, hyponatraemia, impaired balance or visual blurring. Risk rises with the number of such drugs, and two or more together carry markedly higher risk than one. Medicines are among the most modifiable causes of falls in older adults.

Orthostatic hypotension. Measure blood pressure after 5 minutes lying, then standing at 1 minute and 3 minutes. A fall of 20 mmHg or more in systolic or 10 mmHg or more in diastolic pressure confirms it.

Other checks. Look for bradycardia under 50 beats a minute, glucose under 4 mmol/L, sodium under 135 mmol/L, sedation and gait change.

Culprit classes.

• Antihypertensives, diuretics, nitrates and alpha-blockers (doxazosin, prazosin, tamsulosin): postural hypotension and volume depletion.
• Benzodiazepines, zopiclone, zolpidem: sedation and impaired balance.
• Antipsychotics, antidepressants including SSRIs and tricyclics, antiepileptics, gabapentinoids: sedation, hyponatraemia, ataxia.
• Opioids and tramadol: sedation, dizziness.
• Insulin and sulphonylureas: hypoglycaemia.
• Anticholinergics: blurred vision, confusion.
• Digoxin and beta-blockers: bradycardia and heart block.

Reducing risk. If standing systolic pressure is under 110 mmHg or there is a symptomatic postural drop, reduce or stop the most recently added or highest-dose antihypertensive. Replace a night-time sedative with non-drug sleep measures. Replace doxazosin with a calcium channel blocker for hypertension.

Bone protection after a fall. Alendronic acid 70 mg orally once weekly, taken fasting with a full glass of water and kept upright for 30 minutes, for osteoporosis, with calcium and vitamin D. Avoid if creatinine clearance is under 35 mL/min. Review at 5 years.

Vitamin D. Colecalciferol 800 to 1000 units orally daily if deficient or housebound. It does not prevent falls in people with normal levels.

Special groups. In Parkinson disease, postural hypotension from levodopa or dopamine agonists needs dose review. In East Africa, sedating over-the-counter antihistamines, herbal sleep remedies and alcohol add to risk.

Monitoring. Repeat lying and standing blood pressure 2 weeks after any antihypertensive or diuretic change, record falls in a diary, and review gait using the timed up and go test, where 12 seconds or more indicates risk.

Renal and hepatic. Gabapentin, pregabalin, tramadol and morphine accumulate in impaired kidney function, so adjust the dose to creatinine clearance.

Sedative load. Count every drug with sedating effect; two or more is a reason for review.

Stopping. Withdraw one drug at a time, at intervals of 2 weeks, starting with the sedative with least benefit. Taper benzodiazepines by 10% to 25% every 2 to 4 weeks.

Referral and escalation. Refer to a falls service after two falls in a year, any injurious fall, or unexplained syncope. Obtain an ECG for syncope and for bradycardia. Do not stop anticoagulation solely because of falls.