What Medications Increase Fall Risk in Older Adults?

Which Medications Most Commonly Increase Fall Risk?

Several major drug classes are consistently linked to increased fall risk in older adults. The short answer is that any medication affecting the brain, blood pressure, or balance deserves attention — but some categories carry substantially higher risk than others.

The drug classes with the strongest evidence for increasing falls include:

• Benzodiazepines and Z-drugs (sleep and anxiety medications such as Valium, Xanax, Ambien, and Lunesta)
• Antidepressants — both older tricyclic types and newer SSRIs
• Antipsychotics (including Haldol, Risperdal, and Seroquel)
• Opioid pain medications (codeine, hydrocodone, oxycodone, fentanyl)
• Blood pressure and diuretic medications
• Antiepileptic (anti-seizure) drugs
• Muscle relaxants (cyclobenzaprine, methocarbamol, carisoprodol, baclofen)
• Over-the-counter antihistamines and sleep aids containing diphenhydramine (Benadryl, Tylenol PM, Advil PM, Nyquil, Unisom)

Why Older Adults Are More Vulnerable to Medication Side Effects

The same dose of a medication that a younger adult tolerates without difficulty can cause dizziness, confusion, or profound sedation in a person in their 70s or 80s. This is not a matter of individual sensitivity — it reflects predictable changes in how aging bodies process drugs.

As people age, the liver and kidneys become less efficient at breaking down and clearing medications. This means drugs stay in the body longer and reach higher concentrations than they would in a younger person taking the same dose. At the same time, the aging brain becomes more sensitive to the effects of medications that act on the central nervous system — sedatives, sleep aids, antidepressants, and opioids included.

Older persons are extra sensitive to the adverse effects of these medications — a 'normal dose' can be an overdose for many older persons.

This is why a medication that was well-tolerated at age 55 may cause falls at age 75, even without a change in dose. It is also why the drug classes below are more dangerous for older adults than the package insert or prescribing guidelines — written for the general adult population — might suggest.

High-Risk Prescription Drug Categories: What They Are and Why They Cause Falls

Understanding how each drug class causes falls — not just which classes are on the list — helps caregivers have more productive conversations with physicians and pharmacists. The mechanisms differ, and so do the warning signs to watch for.

Benzodiazepines and Z-Drugs

Benzodiazepines — prescribed for anxiety, insomnia, and muscle spasms — and Z-drugs, a newer class of sleep medications, are among the most widely recognized fall-risk drugs for older adults. Both classes cause sedation and slow the brain's ability to process balance signals and react to sudden changes in position.

A 2009 meta-analysis found that benzodiazepines increased fall odds by approximately 57% (odds ratio 1.57) compared to non-use. Critically, both long-acting forms like diazepam (Valium) and short-acting forms like alprazolam (Xanax) carry this elevated risk. Switching from a long-acting to a short-acting benzodiazepine does not meaningfully reduce fall risk — both adjusted odds ratios remain elevated.

The American Geriatrics Society explicitly lists benzodiazepines and Z-drugs on its AVOID list for older adults, noting that they can increase fall risk as well as cause confusion. This guidance applies regardless of whether the drug was originally prescribed for sleep, anxiety, or another condition.

Antidepressants

Among all drug classes studied, antidepressants carry the strongest evidence for fall-risk increase in older adults — an odds ratio of approximately 1.68 (95% CI 1.47–1.91) in a widely cited meta-analysis. This applies to both older tricyclic antidepressants (TCAs) and the newer SSRIs that are now more commonly prescribed.

TCAs such as amitriptyline cause falls primarily through sedation and orthostatic hypotension — the sudden drop in blood pressure that occurs when a person stands up from a seated or lying position. SSRIs carry an additional risk that is less widely known: they reduce bone mineral density, by approximately 3.9% at the hip and 5.9% at the lumbar spine. This means that if a fall does occur, the fracture risk is compounded.

Antipsychotics

Antipsychotic medications — including haloperidol (Haldol), risperidone (Risperdal), and quetiapine (Seroquel) — are prescribed for psychosis, agitation in dementia, and sometimes as sleep aids. They cause falls through sedation, muscle stiffness, and orthostatic hypotension.

Research in nursing home residents with dementia found that antipsychotic use carried a hazard ratio of 1.53 for falls, with a significant dose-response relationship — meaning higher doses produced substantially higher fall risk (hazard ratio 2.78 at higher doses). The American Geriatrics Society also notes that antipsychotics can increase the risk of stroke or death in older adults with dementia, making the risk-benefit calculation particularly important to revisit regularly with a physician.

Opioid Pain Medications

Opioids — including codeine, hydrocodone (Vicodin), oxycodone (Percocet), and fentanyl (Duragesic) — cause falls through sedation, dizziness, and impaired cognitive processing. The risk is highest at strong doses and when opioids are combined with other central nervous system depressants such as benzodiazepines or sleep aids — a combination that amplifies sedation well beyond what either drug would cause alone.

Blood Pressure and Diuretic Medications

Antihypertensive medications and diuretics cause falls primarily through orthostatic hypotension — a drop in blood pressure that occurs when a person moves from lying or sitting to standing. The result is lightheadedness or a brief feeling of faintness that can cause a person to lose their footing before the body has time to compensate.

The risk is especially pronounced in the days and weeks after a dose change. When a blood pressure medication is increased or a new one is added, the body may not immediately adjust. Caregivers should be particularly watchful for dizziness or unsteadiness during any period of medication adjustment.

Antiepileptic Drugs

Anti-seizure medications such as phenytoin, valproate, gabapentin, and carbamazepine increase fall risk through sedative side effects and impaired coordination. They also cause bone thinning over time, which increases the likelihood of a fracture if a fall does occur. This double effect — both raising fall probability and worsening fall consequences — makes antiepileptics worth careful monitoring even when they are medically necessary.

Muscle Relaxants

Muscle relaxants are prescribed for back pain and muscle spasms, but their sedating effects make them poorly suited for older adults. Cyclobenzaprine (Flexeril), methocarbamol (Robaxin), and carisoprodol (Soma) are all on the American Geriatrics Society's AVOID list for older adults.

Among muscle relaxants, baclofen has been associated with the highest fall risk and should be used with particular caution in older adults who are already at elevated risk.

Overlooked Over-the-Counter Medications That Increase Fall Risk

One of the most significant and underrecognized sources of medication-related fall risk in older adults is not prescription drugs — it is products available on any pharmacy shelf without a prescription.

The key ingredient to know is diphenhydramine, sold under the brand name Benadryl and widely used as an antihistamine for allergies and as a sleep aid. Diphenhydramine is a powerful central nervous system depressant that causes sedation, impairs balance, and slows reaction time — effects that are more pronounced and longer-lasting in older adults than in younger users.

What makes diphenhydramine especially hazardous is how many common products contain it. Many older adults take these products without realizing they are ingesting a drug that significantly increases their fall risk:

• Tylenol PM and Advil PM (diphenhydramine combined with pain reliever)
• Aleve PM (diphenhydramine combined with naproxen)
• Nyquil (diphenhydramine in cold and flu formulas)
• Sominex and Unisom (OTC sleep aids)
• Many store-brand allergy and cold products containing diphenhydramine or chlorpheniramine

The deeper problem is that older adults often do not mention OTC medications to their physicians, and physicians do not always ask. Because these products are purchased at a pharmacy without a prescription, many people do not think of them as "real" medications that need to be disclosed.

"I just have been taking the OTC, and I never told my doctor."

This quote comes from a real case documented by the National Council on Aging's HomeMeds program: an 84-year-old who had experienced three falls in three months was found to be taking an OTC medication that had never been disclosed to their doctor. After the medication was discontinued and the person was connected to a falls prevention program, the falls stopped. The OTC disclosure gap is not rare — it is routine.

How Polypharmacy Multiplies Fall Risk

Taking multiple medications simultaneously does not simply add their individual risks together — it compounds them. The combination of drugs can produce interactions and cumulative sedation that none of the medications would cause on their own.

Research consistently shows that taking four or more medications raises fall risk by approximately 1.5 to 2 times compared to taking fewer drugs. This threshold matters because polypharmacy is common: according to CDC data cited by the National Institute on Aging, 83% of U.S. adults in their 60s and 70s used at least one prescription drug in the previous 30 days, and about one-third used five or more.

A particularly dangerous pattern is CNS-active polypharmacy — taking three or more central nervous system-active drugs simultaneously, such as a combination of an antidepressant, a sleep aid, and an opioid pain medication. This combination dramatically increases the risk of falls, overdose, memory problems, and death. A study based on 1.2 million Medicare beneficiaries with dementia found that 13.9% met the definition of CNS-active polypharmacy — a striking proportion given how dangerous the combination is.

What Caregivers Can Do: Medication Review and Questions to Ask

Understanding which medications increase fall risk is only useful if it leads to action. There are three concrete areas where caregivers can make a meaningful difference.

Maintain a Complete Medication List

Keep an up-to-date written list of everything the person is taking — every prescription drug, every OTC product, every vitamin, every supplement, and every herbal remedy — and bring it to every clinical appointment. Include the dose and how often each item is taken. This list is the foundation for any productive medication conversation with a physician or pharmacist.

OTC products and supplements are the most commonly omitted items. Make a point of including them explicitly — they are often the hidden variable in a fall-risk picture that otherwise appears well-managed.

Request a Pharmacist-Led Medication Review

A structured medication review by a pharmacist — using frameworks such as the CDC STEADI medication review approach (updated September 2024) — is an evidence-based fall prevention intervention. Pharmacists are trained to identify unnecessary therapeutic duplication, fall-causing drug combinations, inappropriate medications for older adults, and dosing issues that a busy primary care appointment may not surface.

Ask the primary care physician for a referral to a clinical pharmacist or a medication therapy management (MTM) review. Many Medicare Part D plans cover MTM services at no additional cost.

Questions to Ask at Every Appointment

Bring the complete medication list and ask the prescribing physician and pharmacist these questions at each visit:

• Does any medication on this list increase the risk of falls or dizziness?
• Are there interactions between any of these medications that could cause sedation or balance problems?
• Is the current dose still appropriate given my parent's age and current health status?
• Is there a lower-risk alternative for any of the medications that carry fall risk?
• Are there any medications on this list that are no longer necessary and could be gradually discontinued?
• What side effects should we watch for — particularly dizziness, confusion, or changes in balance?
• Should we check blood pressure in both sitting and standing positions to look for orthostatic hypotension?

When to Request an Urgent Medication Review

Routine medication reviews are valuable, but some situations call for contacting the physician or pharmacist without waiting for the next scheduled appointment. Seek an urgent medication review in any of these circumstances:

• After any fall — even one that did not result in injury. A fall is a signal that something in the risk picture has changed.
• After a new prescription is started, particularly for any of the drug classes listed in this article.
• After a dose change in an existing medication, especially blood pressure drugs or CNS-active medications.
• After noticing new or worsening symptoms such as dizziness when standing, increased unsteadiness, new confusion, or unusual fatigue.
• When an OTC medication has been added to the routine — even if it seems minor.

Medication management works best alongside physical safeguards in the spaces where falls are most likely to occur. Installing grab bars in the bathroom and ensuring safe stair access are practical parallel steps that complement any medication review. For guidance on bathroom safety modifications, see the grab bar installation guide for bathroom safety. If stair access has become a concern, the Stair Lift Cost and Funding Options guide covers options and financial assistance programs.

What Not to Do: Never Stop Medications Abruptly

Reading this article and recognizing that a parent is taking one or more high-risk medications can create a strong impulse to act immediately. That impulse is understandable — but acting on it by stopping a medication without physician guidance can cause serious harm.

The process of reducing or stopping a fall-risk medication — called deprescribing — is a proactive, patient-centered clinical strategy, not a withdrawal of care. When done gradually and under supervision, it can produce meaningful reductions in fall risk. One randomized controlled trial found a 66% reduction in falls when psychotropic drugs were gradually withdrawn under physician oversight compared to continued use — a striking result that underscores both the impact of these medications and the benefit of addressing them carefully.

NIA-funded research has found that when deprescribing is framed as a routine, goal-aligned part of care — rather than as giving up a treatment — patients and caregivers are more open to it. Older adults who prioritize avoiding side effects are often willing to work with their physician to reduce medications that carry more risk than benefit. The conversation is worth having — but it belongs in the clinic, not at the kitchen table.

The most useful next step is to bring the complete medication list — including every OTC product — to the next appointment and ask the physician or pharmacist to review it through a fall-risk lens. The CDC STEADI clinical resources include a Medications Linked to Falls fact sheet (updated September 2024) that healthcare providers can use to guide that review — you can mention it by name when making the request.