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Although falls in older adults are usually multifactorial, the situation is worrying: Many drugs continue to be prescribed to older patients despite their proven contribution to fall risk and related complications. The most recent figures directly illustrate this trend, according to an article on Univadis France, part of Medscape’s professional network. After any fall, clinicians should search for an iatrogenic cause, and in primary prevention each prescription — indication, drug, and dosage — should be reassessed regularly.

REMEDI[e]S, the REview of MEDicinal prescriptions potentially Inappropriate for Seniors, is the result of multidisciplinary work that offers a methodology for analyzing prescriptions. The approach can be summarized as:

• Remove medications that are not indicated or that are redundant.
• Identify clinical issues that would require treatment (therapeutic omissions).
• Identify medications with an unfavorable benefit-risk ratio, questionable efficacy, or inappropriate dose or duration.
• Check for potentially inappropriate interactions in the given patient or between the medications themselves.

The OMéDIT Centre-Val de Loire offers, for its part, a comprehensive geriatric therapeutic booklet that groups together drugs that may be preferentially prescribed for older patients across different indications. (OMéDIT Centre-Val de Loire is a regional French body for drug information and therapeutic evaluation.)

In this framework, several drug families warrant particular attention because of their association with falls. Various professional and institutional bodies publish good-practice texts and recommendations to help clinicians adjust dosages or switch medications.

Psychotropic Drugs

Psychotropic drugs are the leading contributors to falls and remain widely prescribed, including among institutionalized older patients. Key groups include:

• Benzodiazepines (BZDs): Although guidelines advise against prolonged BZD use in older patients with anxiety and depressive disorders, data show prescribing habits in France often run counter to those recommendations. Nonpharmacologic approaches, including cognitive-behavioral therapies, should be favored, as well as certain antidepressants or first-line anxiolytics where appropriate. should be anticipated and discussed with the patient at treatment initiation.
• Z-drugs: Zopiclone may be considered as a hypnotic, at half the adult dose and for up to 2 weeks at bedtime, if needed.
• Other antidepressant classes — tricyclics (including imipraminic agents), selective serotonin reuptake inhibitors (SSRI), and serotonin-norepinephrine reuptake inhibitors — on managing depression in older adults: They exclude tricyclic antidepressants from first-line use and instead preferentially recommend an SSRI, principally sertraline.
• Antipsychotics: First- and second-generation antipsychotics should be used in geriatric settings only for certain severe manifestations or when nonpharmacologic approaches have failed. When treatment is warranted, oral atypical antipsychotics are preferable, and the choice should be based on the expected benefit-risk balance for the individual patient.

Cardiovascular Drugs

In a 2025 report on managing cardiovascular risk factors in people aged 75 years or older, the French National Academy of Medicine reminds clinicians that monotherapy should be preferred as first-line treatment with one of the following four classes of antihypertensives: thiazide or thiazide-like diuretics, calcium-channel blockers — particularly dihydropyridines — angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers. However, the hypotensive properties (notably orthostatic effects) or bradycardic effects of many drug classes — such as thiazide diuretics, centrally acting antihypertensives, alpha-blockers, and some nonselective beta blockers — can increase fall risk. Prescribing should therefore be cautious, and blood-pressure targets should be adapted to the patient’s age and frailty. For fall prevention, bisoprolol or nebivolol are considered appropriate. Authorities also provide a memo sheet to help optimize antihypertensive treatment in older people with comorbidities.

Antidiabetic Drugs

Drugs that expose older patients to dehydration or hypoglycemia raise fall risk: sulfonylureas, glinides, and insulins. Metformin remains the first-line medication. DPP-4 inhibitors, SGLT2 inhibitors, and GLP-1 receptor agonists do not carry the same dehydration or hypoglycemia risks and may be appropriate depending on indications and the patient’s profile. Opinion 21 of the French-speaking Diabetes Society reminds clinicians of the vigilance required when managing antidiabetic therapy in older patients.

Anticholinergics

Many drugs have anticholinergic activity and are used for diverse indications. Their peripheral and central effects can directly or indirectly promote falls. For each relevant prescription, it is important to reassess whether the drug is appropriate for the intended indication and to seek a nonanticholinergic alternative when possible. A calculator of anticholinergic burden is available and can help identify the risk associated with each drug.

Analgesics

Nefopam is not recommended for older patients because of its high anticholinergic properties and the adverse effects it can cause in this population. When a strong analgesic is necessary, opioids (morphine, oxycodone, and fentanyl) are preferred: Although their use requires great caution and a careful benefit-risk assessment, these drugs are available in dosages and formulations that allow precise individualization of dosing. Titration should be very gradual, and a laxative should be prescribed concurrently to prevent constipation. Regular reassessment of opioid prescriptions is essential; in addition to fall risk, the risk for confusion must be closely monitored.

If fall risk is linked to each of these therapeutic classes individually, that risk can be amplified by combinations of therapies — interactions and additive effects that clinicians should identify and avoid.

This story was translated from Univadis France edition.