Opioids in Older Adults: Managing Falls, Delirium, and Safe Dosing

Older adults are more likely to be prescribed opioids than ever before-and more likely to suffer serious harm from them. While these drugs can ease pain, they also raise the risk of falls, confusion, hospital stays, and even death in people over 65. The problem isn’t just overprescribing. It’s that doctors often use the same dosing rules for seniors as they do for younger patients, even though aging changes how the body handles drugs. This mismatch puts older adults in danger, especially those with dementia, mobility issues, or multiple chronic conditions.

Why Opioids Are Riskier for Older Adults

As we age, our bodies change in ways that make opioids more dangerous. Kidneys and liver don’t clear drugs as quickly. Body fat increases while muscle mass drops, so opioids build up in the system longer. The blood-brain barrier becomes more porous, letting more of the drug reach the brain. These changes mean a dose that’s safe for a 40-year-old could be toxic for a 75-year-old.

A 2011 study found that, on average, 80 adults aged 65 and older visited emergency rooms every day because of problems with narcotic pain relievers. Seven of those visits involved heroin. That’s not just misuse-it’s often a result of unintended side effects from prescribed medication. Emergency visits for opioid issues in this age group jumped 112% between 2005 and 2014. Inpatient stays rose by 85% in the same period.

Falls: A Silent Epidemic

Falls are the leading cause of injury-related death in older adults. Opioids make them far more likely. The drugs cause drowsiness, dizziness, low blood pressure when standing up, and slowed reaction times. Even weak opioids like tramadol increase fall risk-not just from sedation, but by triggering hyponatremia, a drop in sodium levels that causes confusion and unsteadiness.

One study of 2,341 adults over 60 found that those taking opioids had a 6% fracture rate over 33 months, compared to 4% for those not on opioids. While the difference wasn’t statistically significant, the trend is clear: opioids impair balance. And for someone who’s already at risk for falls, even a small increase in dizziness can mean a broken hip-and a lifetime of disability.

Delirium: When Pain Medication Causes Confusion

Delirium is sudden, severe confusion. It’s often mistaken for dementia or depression, especially in older adults. But opioids are a major trigger. A 2023 study from the Danish Dementia Research Centre tracked 75,471 people over 65 with dementia. Of those, 31,619 were prescribed opioids. The results were alarming: those who started opioids had an elevenfold higher risk of dying in the first two weeks compared to those who didn’t.

This isn’t about addiction. It’s about brain chemistry. Opioids interfere with neurotransmitters that control attention, memory, and awareness. In someone with existing cognitive decline, even a low dose can push them into delirium. Many doctors don’t connect the dots. They see confusion and assume it’s just dementia getting worse. But sometimes, it’s the medication.

Dose Adjustments: Start Low, Go Slow

There’s no one-size-fits-all dose for older adults. The standard advice is simple: start low, go slow. That means beginning with 25% to 50% of the dose you’d give a younger adult. For example, if a typical starting dose for a 40-year-old is 10 mg of oxycodone every 6 hours, a 75-year-old might start with 2.5 mg every 8 hours.

Monitoring is just as important as the starting dose. Doctors should check for signs of sedation, unsteadiness, or mental fog within days of starting or changing the dose. If the patient seems drowsy, confused, or has trouble walking, the dose should be lowered-or stopped.

Tools like STOPPFall help clinicians decide when to reduce or stop opioids in people who’ve already fallen or are at risk. It’s not about denying pain relief. It’s about finding safer ways to manage it.

Drug Interactions: The Hidden Danger

Most older adults take multiple medications. Opioids don’t exist in a vacuum. They interact dangerously with benzodiazepines (like Xanax), sleep aids, antidepressants, and even some heart medications. These combinations amplify sedation and respiratory depression.

Tramadol is especially risky because it’s metabolized by two liver enzymes-CYP2D6 and CYP3A4. Many common drugs block these enzymes, causing tramadol to build up to toxic levels. A patient on tramadol and an SSRI antidepressant might not realize their confusion and falls are drug-induced.

A 2019 study of 297,314 patients found that those who took opioids for 180 days or more over 3.5 years had more than double the risk of heart attack. Another study of over 11,000 people showed a 28% higher chance of heart attack while actively using opioids. The link isn’t fully understood, but it’s real-and it’s another reason to avoid long-term use.

Deprescribing: When Less Is More

Many older adults stay on opioids for years, even when they no longer help. They don’t want to be seen as complainers. Doctors don’t want to risk worsening pain. But staying on opioids too long leads to physical dependence-even in just a few days. Withdrawal can be severe: nausea, sweating, anxiety, and worsening pain.

Deprescribing isn’t about quitting cold turkey. It’s a slow, planned process. Reduce the dose by 10% to 25% every 1 to 2 weeks. Watch for withdrawal symptoms. Offer non-opioid alternatives like acetaminophen, physical therapy, heat therapy, or nerve blocks.

A 2021 study in JAMA Network Open found that nearly half of primary care doctors felt unsure about how to safely taper opioids in older patients. Patients, meanwhile, often fear addiction more than side effects like dizziness or confusion. That gap in understanding makes conversations hard. Trust is key. If the patient doesn’t feel heard, they won’t agree to change.

What Works Better Than Opioids

For chronic pain in older adults, non-drug options often work better-and are safer. Physical therapy improves strength and balance, reducing both pain and fall risk. Cognitive behavioral therapy helps people cope with pain without relying on pills. Acupuncture, massage, and tai chi have shown real benefits in clinical trials.

Topical pain relievers (like lidocaine patches or capsaicin cream) deliver relief without systemic side effects. For nerve pain, gabapentin or pregabalin are often safer than opioids. For arthritis, NSAIDs like naproxen can help-if kidney function is normal.

The goal isn’t to eliminate all pain. It’s to manage it in a way that doesn’t steal mobility, clarity, or life.

The Bigger Picture

The opioid crisis didn’t skip older adults. It hit them harder. Between 2005 and 2014, emergency visits for opioid problems in this group surged. Veterans over 50 with opioid use disorder were twice as likely to die as younger veterans-mostly from accidental overdoses. People with dementia who started opioids were 11 times more likely to die within two weeks.

The medical system is slowly catching up. Guidelines from the CDC and FDA now stress caution in prescribing opioids to older adults. Professional groups are pushing for geriatric-specific protocols. But change is slow. Many prescriptions are still written without considering age-related risks.

The solution isn’t to stop all opioids. It’s to use them smarter. Start with the lowest possible dose. Watch closely. Re-evaluate every few weeks. And always ask: Is this helping more than it’s hurting?