Medications Associated with Higher Risk of Perioperative Falls

Falls are among the most frequent and costly complications following surgery, often leading to prolonged hospitalizations, loss of independence, and higher morbidity. For anesthesiologists, who directly influence perioperative prescribing practices, it is essential to recognize medications that elevate fall risk. The perioperative period creates a unique vulnerability: patients often receive sedatives, analgesics, and sleep aids while recovering from anesthesia, all of which can impair balance, attention, and orthostatic regulation. Careful medication stewardship can reduce fall risk without compromising pain control or patient comfort.

Sedative–hypnotics, especially the non-benzodiazepine “Z-drugs” such as zolpidem, are common medications in the perioperative period and may contribute to the risk of falls. In a large case–control study of hospitalized adults, zolpidem was independently associated with increased odds of inpatient falls, even after accounting for comorbidity and concomitant medication use. Mechanistically, sedative-hypnotics impair balance, increase amnesia, and contribute to nocturnal confusion, all of which can impact mobility, particularly in the first postoperative night. For anesthesiologists, avoiding routine initiation of zolpidem postoperatively and instead prioritizing nonpharmacologic sleep strategies represents an actionable and evidence-based step.

Benzodiazepines, traditionally viewed as strong contributors to delirium and falls, have a more nuanced profile in recent literature. A 2023 systematic review and meta-analysis found that perioperative benzodiazepines did not significantly increase delirium risk overall and were effective in preventing intraoperative awareness. However, in older, frail, or cognitively impaired patients, benzodiazepines remain problematic due to sedation, impaired motor coordination, and potentiation of other CNS depressants. In practice, this means reserving benzodiazepines for well-justified indications, tailoring dosing, and avoiding them in high-risk patients.

Gabapentinoids, such as gabapentin and pregabalin, are increasingly scrutinized for their role in perioperative safety. Once widely prescribed for opioid-sparing analgesia, they are now associated with significant adverse events. A nationwide cohort study of older surgical patients demonstrated that perioperative gabapentin use was linked to increased risk of delirium, new antipsychotic prescriptions, and pneumonia. Separately, a 2024 analysis found gabapentinoid exposure to be associated with a higher risk of hip fractures, particularly among frail patients and those with kidney disease. For anesthesiologists, this means gabapentinoids should be reserved for clear neuropathic indications, prescribed at the lowest effective dose, and carefully adjusted for renal function. They should also be avoided in combination with other sedatives whenever possible.

Opioid medications remain a cornerstone of perioperative pain management but are also significant contributors to fall risk. Their sedative and cognitive effects impair reaction time and balance, while their potential to induce orthostatic hypotension increases instability during early ambulation. When combined with benzodiazepines, gabapentinoids, or hypnotics, opioids can have synergistic effects that magnify fall risk. Effective strategies to mitigate this include the use of multimodal analgesia, regional techniques, and early de-escalation of opioid therapy. Opioid stewardship not only reduces fall risk but also enhances recovery and patient satisfaction.

Practical interventions can be embedded throughout the perioperative pathway. Preoperatively, anesthesiologists should identify high-risk patients—those who are aged 65 or older, frail, cognitively impaired, or with renal insufficiency—and reconcile home sedatives. Intraoperatively and in the PACU, minimizing sedative burden, avoiding routine benzodiazepines, and carefully reviewing postoperative sleep orders are key steps. On the ward, nonpharmacologic sleep hygiene strategies should be prioritized, and if hypnotics are absolutely required, the lowest effective dose should be chosen and not combined with opioids or gabapentinoids. Nursing fall-prevention protocols should also be coordinated with prescribing practices to ensure safe mobilization.

Anesthesiologists play a central role in mitigating perioperative fall risk through medication choices. The most concerning agents are sedative–hypnotics, benzodiazepines in vulnerable populations, gabapentinoids in older or renally impaired adults, and opioids, especially when used in combination. Reducing unnecessary sedative load, tailoring prescriptions to individual risk profiles, and embedding fall-prevention strategies into perioperative care pathways can meaningfully improve patient safety.

References

1. Kronzer VL, Wildes TS, Avidan MS. Review of perioperative falls. Br J Anaesth. 2016;117(6):720-732. doi: 10.1093/bja/aew377.
2. Kolla BP, Lovely JK, Mansukhani MP, Morgenthaler TI. Zolpidem is independently associated with increased risk of inpatient falls. J Hosp Med. 2013;8(1):1-6. doi: 10.1002/jhm.1985.
3. Park CM, Inouye SK, Marcantonio ER, et al. Perioperative gabapentin use and in-hospital adverse clinical events among older adults after major surgery. JAMA Intern Med. 2022;182(11):1117-1127. doi: 10.1001/jamainternmed.2022.3680.
4. Leung MTY, Turner JP, Marquina C, Ilomäki J, Tran T, Bykov K, Bell JS. Gabapentinoids and risk of hip fracture. JAMA Netw Open. 2024;7(11):e2444488. doi: 10.1001/jamanetworkopen.2024.44488.
5. Wang E, Belley-Côté EP, Young J, et al. Effect of perioperative benzodiazepine use on intraoperative awareness and postoperative delirium: a systematic review and meta-analysis. Br J Anaesth. 2023;131(3):302-313. doi: 10.1016/j.bja.2022.12.001.