Which medications can cause falls in the elderly? A focus on benzodiazepines

As we age, the fear of accidental falls is understandable since they can quickly lead to loss of independence and an urgent need for institutional care. According to the Canadian Community Health Survey, approximately a third of seniors fall at least once per year. It’s important to understand what causes these falls and, in particular, which medications cause falls in the elderly because prescription drug use increases with age.

A study published in the Journal of the American Medical Association found that medical treatment in an emergency department is required in almost one-tenth of all falls due to fractures and head injuries.

The table below shows the four main types of medications that have been associated with increased fall risk in the elderly. These drugs can increase that risk due to side-effects such as drowsiness, dizziness, and low blood pressure. This article focuses on sedatives and hypnotics called benzodiazepines, their proper use, and what to do to make sure they don’t cause unintended side-effects such as dizziness and falls.

How individuals respond to each type of drug and dose can vary greatly. Much of that variation depends on your genetics. For some people, these prescribed drugs make you more likely to lose balance and fall—and the risk can be even greater if you take multiple medications at the same time.

What are benzodiazepines? Are benzodiazepines bad for the elderly?

Benzodiazepines, commonly called benzos, include drugs like Valium, Ativan, and Xanax. Often prescribed for panic attacks, anxiety and insomnia, benzodiazepines are meant to be taken short-term, normally for about two weeks. The use of these drugs has risen among older people, even though they are particularly vulnerable to the drugs’ ill effects. A recent New York Times article outlines some of the dangers of these drugs for seniors. Medical experts believe that too many older people are prescribed benzos and take them for long periods. Almost 80% of all seniors prescribed benzodiazepines continue to take them for over two years. Unfortunately, stopping benzodiazepines suddenly after long-term use can be both difficult and dangerous.

The most serious consequences of benzodiazepines for seniors are falls leading to fractures because the drugs can cause dizziness. The American Geriatrics Society now recommends that doctors first choose other medications instead of benzodiazepines to treat insomnia, agitation, or delirium in the elderly. Their review found that the risk of falls, motor vehicle accidents and hip fractures leading to hospitalization and death can more than double in older adults taking benzodiazepines.

How do benzodiazepines work? Why do they increase the risk of falling?

Benzodiazepines make you metabolize a key hormone in your brain, called GABA, more slowly. GABA is responsible for sleep and relaxation, and the level of GABA in your brain usually peaks when you are asleep. There are two reasons why benzodiazepines may cause dangerous side effects:

• If you use benzodiazepines for an extended time, you may need more GABA to help you feel relaxed. This, in turn, may lead your doctor to prescribe a higher dose of the drug that could make you overly tired or dizzy and lead to a fall. As noted, they should only be used short-term, usually for no longer than two weeks.
• Benzodiazepines are processed, or metabolized, by your liver. Some people don’t properly metabolize the dose they’re prescribed. If you process the drug too slowly, it builds up in your system. This leads to dizziness or drowsiness that may result in a fall.

A personalized approach can help avoid medication side-effects and reduce falls

How your body metabolizes benzodiazepines is based on your unique DNA. Various liver enzymes metabolize different benzodiazepine drugs. The drugs’ effectiveness and the risk of side effects are related to individual genetic variations in people and the level of enzymes in their liver. The Pillcheck test, which is based on the science of pharmacogenetics, lets you know how well your body metabolizes these medications. It can help you and your doctor understand if benzodiazepines are likely to be effective, your risk of side effects, the right dose, or whether you should consider alternative medications.

How do benzodiazepines interact with other medications?

Sleep problems, chronic pain and high blood pressure occur together in older individuals. Determining how individuals metabolize the different medications prescribed for these conditions can significantly reduce multiple preventable risks. A recently published Pillcheck study in long-term care showed the benefit of matching drug treatment to people’s DNA. The study found that 80% of the patients take two or more medications that could be tailored to their genetics.

Summary

• The risk of falls, motor vehicle accidents and hip fractures leading to hospitalization and death can more than double in older adults taking benzodiazepines.
• Personalized medication management can help avoid the risk of falls and fractures in the elderly.
• Pillcheck, an easy DNA-based pharmacogenetic test that includes a medication review by an expert pharmacist, can help address these serious issues before they occur. The Pillcheck report covers benzodiazepines and most other medications that are commonly prescribed for older adults.

See our in-depth benzodiazepine blog for more information

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Sources:

Canadian statistics on falls in seniors:
https://www.canada.ca/en/public-health/services/health-promotion/aging-seniors/publications/publications-general-public/seniors-falls-canada-second-report.html

JAMA study investigating interventions to prevent falling in seniors:
Comparisons of Interventions for Preventing Falls in Older Adults: A Systematic Review and Meta-analysis. Tricco AC, et al. Journal of the American Medical Association. 2017: Volume 318(17), p1687-1699.

Drug-related falls in older patients: implicated drugs, consequences, and possible prevention strategies.
Ther Adv Drug Saf. 2013 Aug; 4(4): 147–154.

Individualized Medication Management in Ontario Long-Term Care Clinical Impact on Management of Depression, Pain, and Dementia.
JAMDA, VOLUME 21, ISSUE 6, P823-829.E5, JUNE 01, 2020