Older Adults
Sonya Collins
Falls are the leading cause of both nonfatal and fatal injuries in older adults, according to CDC. One in four older adults reports a fall every year. Certain medications, including vestibular suppressants, contribute to this burden.
The American Geriatric Society discourages routine use of vestibular suppressants in older adults due to the drugs’ potential to raise risk for falls. A study published online February 4, 2025, in the Journal of the American Geriatrics Society underscores the dangers of these medications in older patients.
“These medications should be prescribed with caution, particularly in frail older adults, those with a history of falls, or those with gait and balance impairments. In many cases, nonpharmacologic management is safer and more effective,” said Schelomo Marmor, PhD, a study coauthor and co-director of Clinical Quality, Outcomes, Discovery, and Evaluation Core in the Center of Learning Health System Sciences at the University of Minnesota Medical School.
Dangers of vestibular suppressants
Researchers analyzed health insurance claims of 190,348 adults aged 65 years and over who had sought medical attention for dizziness between January 2006 and December 2015. Thirty-two percent filled a prescription for a vestibular suppressant. Among those taking vestibular suppressants, 8% had a fall that required medical care within 60 days of filling the prescription.
“While dizziness itself is indeed a risk factor for falls, we found that after controlling for multiple known risk factors for falls, patients prescribed vestibular suppressants were still significantly more likely to experience falls requiring medical attention,” Marmor said.
The study controlled for risks associated with comorbidity burden and whether the patient presented to the emergency department or ambulatory care for dizziness, as well as the patient’s age, sex, and race and ethnicity.
Patients taking benzodiazepines were four times more likely to fall. Those taking anti-emetics, such as meclizine, were twice as likely to fall as patients who were not taking any vestibular suppressants.
“These findings reinforce concerns raised by the AGS Beers Criteria, which caution against the use of these agents in older adults,” said Marmor.
A companion study published online further emphasizes the concerns that vestibular suppressants raise. Among 805,454 adults aged 18 years to 87 years seeking medical attention for dizziness, meclizine increased fall risk among all adults aged 65 years and over and among those aged 18 years to 64 years who already had other risk factors for falls.
While these medications offer immediate relief of vertigo, Marmor said, longer-term use of meclizine and other antihistamines can be “particularly problematic in older adults due to their association with dizziness, sedation, delirium, and long-term cognitive decline. Benzodiazepines, meanwhile, are known to impair coordination, slow reaction times, and lead to sedation and confusion, especially in patients with decreased hepatic metabolism.”
Alternatives to vestibular suppressants
Reducing risks posed by vestibular suppressants is not a question of lowering the dose or prescribing a different medication.
“In cases of acute vestibular neuritis, a short course of 1 to 3 days of vestibular suppressants may be justified to relieve disabling symptoms, but prolonged use can delay central compensation and recovery,” Marmor said.
Instead, nonpharmacological treatment might be more suitable for many patients. For example, first-line treatment for patients with benign paroxysmal positional vertigo is a canalith repositioning procedure. Typically, patients can access this procedure through their physician or a physical therapist.
“The overall emphasis should be on accurate diagnosis and targeted treatment rather than symptom masking with medications,” Marmor said.
Screen patients for fall risk
For pharmacists dispensing vestibular suppressants to older adults, Marmor recommends the following:
Screen for fall risk by asking about history of falls, balance issues, and sedating medications.
Counsel patients on the medication’s potential for causing dizziness, sedation, and falls.
Where appropriate, contact prescribers to encourage deprescribing if the indication is unclear and to suggest alternatives such as vestibular rehab or referral to a dizziness clinic.
“Pharmacists are critical to reducing fall risk in older adults. They are uniquely positioned to spot these risks at the point of care, and their input can prevent serious injury.” ■