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Which medications can cause falls in older adults? A focus on benzodiazepines

Veronika Litinski, MSc Medicinal Chemistry, MBA4 Nov 2026

Falls are one of the main reasons older adults lose their independence. According to the Public Health Agency of Canada, between 20% and 30% of Canadians aged 65 and older fall each year, and falls are the leading cause of injury-related hospital stays in this age group. Many things contribute to falls, including weaker muscles, poor balance, vision problems and hazards at home. Medications are one of the most common causes, and one of the easiest to change. Because people take more medications as they age, it is important to know which ones raise the risk of falling. This article focuses on benzodiazepines and sleeping pills, how to reduce their risks, and how pharmacogenetic testing can help.

Which medications increase the risk of falls?

Medications that increase the risk of falls are often called fall-risk-increasing drugs. They can cause drowsiness, dizziness, confusion, slower reactions, blurred vision or a drop in blood pressure when standing up. A European expert group listed the main classes in a tool called STOPPFall:

Benzodiazepines and related sleeping pills, such as alprazolam, clonazepam, diazepam, lorazepam, oxazepam and temazepam, and the “Z-drug” zopiclone.
Antidepressants, including tricyclic antidepressants such as amitriptyline and SSRIs.
Antipsychotics, sometimes prescribed for agitation in dementia.
Opioids, such as codeine, tramadol, oxycodone and hydromorphone.
Antiepileptics, including gabapentin and pregabalin used for nerve pain.
Blood pressure medications, especially alpha-blockers such as doxazosin, prazosin and terazosin, which are also used for prostate symptoms, and other medications that can lower blood pressure too much, such as diuretics and some heart medications.
Anticholinergic medications, such as some bladder medications and older antihistamines like diphenhydramine.

The risk is higher when several of these medications are taken together, and how strongly each one affects you depends partly on your genes.

What are benzodiazepines, and why are they a concern for older adults?

Benzodiazepines, often called “benzos”, are prescribed for anxiety, panic attacks and insomnia. Zopiclone is not a benzodiazepine, but it works in a similar way and has similar risks. These medications are meant for short-term use, usually no more than two to four weeks. Many older adults, however, take them for months or years.

Older adults are more sensitive to these medications, and their bodies often clear them more slowly. The American Geriatrics Society advises doctors not to use benzodiazepines or other sedative-hypnotics as the first choice for insomnia, agitation or delirium in older adults, because large studies show that the risk of falls, hip fractures and car crashes can more than double. The 2023 Beers Criteria, a widely used list of medications to avoid in older adults, recommends avoiding both benzodiazepines and Z-drugs in most cases. Long-term use is also linked with memory problems and dependence.

How do benzodiazepines work, and why do they increase the risk of falling?

Benzodiazepines strengthen the effect of GABA, a natural chemical messenger that calms brain activity. This is what makes them relaxing and sleep-inducing, but it also slows reactions and affects balance and coordination, especially the morning after a bedtime dose. Two things make side effects more likely:

Tolerance. With regular use, the brain adapts and the same dose works less well. This can lead to higher doses, which add to drowsiness and dizziness.
Slow clearance. Some benzodiazepines, such as diazepam, stay in the body for a long time, and levels can build up with each dose, especially in older adults and in people whose liver enzymes work more slowly.

How can benzodiazepines be stopped safely?

Do not stop a benzodiazepine suddenly after regular use, because this can cause withdrawal symptoms such as anxiety, insomnia and, rarely, seizures. A slow, planned reduction works well. The Canadian deprescribing guideline recommends offering a slow taper to every adult aged 65 or older who takes a benzodiazepine or Z-drug for insomnia, for example by reducing the dose by about 25% every two weeks, and more slowly near the end.

Older adults often succeed. In the EMPOWER trial in Quebec, long-term benzodiazepine users aged 65 and older who received an educational brochure about the risks and a step-by-step tapering plan were much more likely to stop: 27% had stopped after six months, compared with 5% of those who received usual care. Cognitive behavioural therapy for insomnia (CBT-I) is the recommended first treatment for long-term sleep problems and can help during tapering.

What else helps prevent falls?

A large review of fall-prevention trials found that exercise, especially when combined with vision checks and changes to make the home safer, reduced injurious falls in older adults. A regular review of all medications by a doctor or pharmacist is another important step. Read more about how drug metabolism changes with age.

How can pharmacogenetic testing help?

There is no pharmacogenetic dosing guideline for most benzodiazepines yet, and genes affect them in different ways:

Diazepam and clobazam are partly broken down by CYP2C19. People who are poor metabolizers clear them more slowly, and the clobazam label recommends a lower dose for them.
Alprazolam and zopiclone are broken down by CYP3A4, so medications that block this enzyme, such as clarithromycin and some antifungals, can raise their levels.
Lorazepam, oxazepam and temazepam are not broken down by CYP enzymes, so genetic results have little effect on them.

Pharmacogenetic testing is most useful for the other fall-risk medications that older adults often take, many of which have guidelines from the Clinical Pharmacogenetics Implementation Consortium (CPIC):

Tricyclic antidepressants and many SSRIs, based on CYP2D6 and CYP2C19. Poor metabolizers can build up high levels that cause drowsiness and dizziness.
Codeine and tramadol, based on CYP2D6. Ultrarapid metabolizers can have strong side effects such as heavy sedation, while poor metabolizers get little pain relief. Read more about why codeine does not work for everyone.
Metoprolol, a beta-blocker, based on CYP2D6. Poor metabolizers have higher levels and a slower heart rate, so CPIC advises starting at a low dose and increasing it gradually.

In a Pillcheck study in four Ontario long-term care homes, 94% of residents who were tested took two or more medications with pharmacogenetic guidance. Of the residents taking antidepressants, 64% had altered CYP2C19 or CYP2D6 metabolism and could benefit from a dose change or a different antidepressant.

A Pillcheck test reports CYP2D6, CYP2C19, CYP3A4 and other genes that affect antidepressants, opioids, heart medications and many other drugs commonly taken by older adults. A pharmacist reviews your results together with all your medications, which helps your doctor spot medications and doses that could raise your risk of falling. Read more in our in-depth article on benzodiazepines.

Pillcheck testing is performed in CAP- and COLA-accredited clinical genetic laboratories located in Canada. Pillcheck reports on 24 genes, increasing coverage with new guidelines and drug labels (see the genes tab), and covers 355 medications, which account for over 70% of dispensed prescriptions. The Pillcheck test panel ensures high accuracy for people of non-European and admixed ancestries. Your results last a lifetime, and report updates are free of charge.

Summary

Between 20% and 30% of older Canadians fall each year, and medications are a common, preventable cause.
Benzodiazepines, Z-drugs, antidepressants, antipsychotics, opioids, antiepileptics, some blood pressure medications and anticholinergics all increase fall risk, especially when combined.
Benzodiazepines and Z-drugs can more than double the risk of falls and hip fractures in older adults and are best avoided for insomnia.
Do not stop benzodiazepines suddenly. A slow taper with your doctor or pharmacist works for many older adults, and CBT-I can help with sleep.
Pharmacogenetic testing helps choose safer doses of antidepressants, opioids and metoprolol, which are often taken alongside benzodiazepines.

Frequently asked questions

Are benzodiazepines safe for older adults?

They are generally not recommended as a first choice for older adults, because they increase the risk of falls, fractures, confusion and car crashes. If you take one, talk to your doctor or pharmacist about whether you still need it.

How do I stop taking a benzodiazepine?

Work with your doctor or pharmacist on a slow tapering plan, often reducing the dose by about 25% every two weeks. Do not stop suddenly after regular use.

Can a genetic test tell me if a benzodiazepine is safe for me?

Only partly. Genes affect diazepam and clobazam, but not lorazepam, oxazepam or temazepam. Genetic testing is most helpful for the other fall-risk medications you may take, such as antidepressants, opioids and metoprolol.

Which sleep treatments are safer than sleeping pills?

Cognitive behavioural therapy for insomnia (CBT-I) is the recommended first treatment for long-term insomnia. Ask your doctor or pharmacist about other options that do not increase the risk of falls.