Falls Risk Assessment

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Benzodiazepines

  • Several studies have found benzodiazepines are associated with a higher risk of falling.1,2,3,4
  • Increased risk of over-sedation, drowsiness, ataxia, confusion, and falls.2
  • Should be avoided in high fall risk patients, if possible.2
  • Evidence suggests both long and short-acting BZDs increase the risk of falls, but short-acting agents are preferred.3
  • Recommended to use the lowest possible dose for the shortest period of time.3,5
  • For anxiety, consider tapering and trialing an SSRI or SNRI (see section on antidepressants appendix G).3
  • For insomnia, consider alternative therapies to address underlying cause of insomnia.5
  • Strong evidence to suggest psychotropic agents including benzodiazepines are associated with a higher risk of hip fractures.1,6,7
  • One study has shown that patients taking higher than recommended doses of benzodiazepines had a much higher risk of hip fracture, compared to patients on a standard dose.1
  • Some evidence suggests that within the first two weeks of benzodiazepine use has shown the highest rates of falls and injurious falls.7

Short-term use:

  • PRN preferred to regular use.3

Long-term use:

  • Consider dose reductions or withdrawal if possible.3

Preferred agents:

  • Lorazepam and oxazepam for anxiety as they have shorter half-lives.3
  • Temazepam for insomnia, or low dose zolpidem or zopiclone. It is important to address the underlying cause of insomnia and discuss sleep hygiene with the patient.3
  • Review any medications that may contribute to the patient’s insomnia.

Agents to avoid:

  • Diazepam, nitrazepam, flurazepam and flunitrazepam should be avoided as they have the longest half-lives and accumulation risks in elderly.3

References

  1. Cumming RG. Epidemiology of Medication-Related Falls and Fractures in the Elderly. Drugs and Aging 1998 January; 12(1):43-53.

  2. Australian Medicines Handbook 2016. Adelaide: Australian Medicines Handbook Pty Ltd; 2015 January. 

  3. Ferreri S, Roth MT, Casteel C, Demby KB, Blalock SJ. Methodology of an ongoing, randomized controlled trial to prevent falls through enhanced pharmaceutical care. Am J Geriatr Pharmacother. 2008;6(2):61-81.

  4. Park H, Satoh H, Miki A, Urushihara H, Sawada Y. Medications associated with falls in older people: systematic review of publications from a recent 5-year period. Eur J Clin Pharmacol 2015 September 26; 71:1429-1440.

  5. Bulat T, Castle SC, Ruthledge M, Quigley P. Clinical practice algorithms: medication management to reduce fall risk in the elderly—part 3, benzodiazepines, cardiovascular agents, and antidepressants. J Am Acad Nurse Pract. 2008; 20(2):55-62.

  6. Coupland C, Dhiman P, Morriss R, Barton G, Hippisley-Cox J. Antidepressant use and risk of adverse outcomes in older people: population based cohort study. BMJ 2011 August 2; 343:1-15.

  7. Huang AR, Mallet L, Rochefort CM, Eguale T, Buckeridge DL, Tamblyn R. Medication-Related Falls in the Elderly. Causative Factors and Preventive Strategies. Drugs Aging 2012; 29(5):359-376.

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