Opioids in Older Adults: How Falls, Delirium, and Dose Errors Put Lives at Risk

Every year, tens of thousands of older adults end up in emergency rooms because of opioids-medications meant to help with pain but that often do more harm than good in people over 65. It’s not just about addiction. It’s about falls, delirium, and doses that are way too high for their bodies. These aren’t rare side effects. They’re predictable, preventable, and happening far too often.

Why Older Bodies Handle Opioids Differently

Your body changes as you age, and those changes affect how drugs work. Older adults have less muscle mass, more body fat, and kidneys and livers that don’t process drugs as quickly. That means opioids stick around longer and build up in the system. Even a dose that’s safe for a 40-year-old can be dangerous for a 75-year-old.

Another big issue: the blood-brain barrier weakens with age. This protective layer that keeps toxins out becomes more porous. So more of the drug gets into the brain, leading to stronger sedation, confusion, and dizziness. It’s not that older people are ‘sensitive’-it’s that their biology has changed, and most prescriptions don’t account for that.

Studies show that older adults are twice as likely to die from opioid-related causes compared to younger people with the same condition. In one study of veterans over 50 with opioid use disorder, death rates were double those of younger veterans. And it’s not just overdoses. Many die from falls, heart attacks, or sudden confusion that leads to hospitalization.

Falls: The Silent Epidemic

Falls are the leading cause of injury-related death in people over 65. Opioids make them far more likely. How? Three main ways:

• Sedation-opioids slow down the central nervous system, making reactions sluggish.
• Orthostatic hypotension-a sudden drop in blood pressure when standing up, causing dizziness or fainting.
• Impaired balance and coordination-even weak opioids like tramadol can mess with your sense of where your body is in space.

Tramadol is especially risky. It can cause hyponatremia-low sodium in the blood-which leads to confusion, nausea, and dizziness. Combine that with other medications like diuretics or antidepressants, and the risk spikes even higher. One study of 2,341 adults over 60 found that those on opioids had a 28% higher chance of breaking a bone over three years. That’s not a small risk-it’s a major red flag.

And here’s the twist: some doctors prescribe opioids to treat chronic pain because they think it will help people move better. But if the opioid causes dizziness or weakness, the person ends up falling more. Pain control doesn’t always mean fewer falls. Sometimes, it’s the opposite.

Delirium: When Opioids Fog the Mind

Delirium isn’t just ‘being confused.’ It’s a sudden, severe change in mental state-trouble focusing, hallucinations, agitation, or extreme sleepiness. It’s common in hospitals, but it’s also happening at home, often because of opioids.

A landmark 2023 study tracked 75,000 Danes over 65 with dementia. Those who started opioids within two weeks of diagnosis had an elevenfold higher risk of dying than those who didn’t. That’s not a typo. Eleven times. And this wasn’t just in the hospital-it happened at home, often without anyone realizing opioids were the cause.

Delirium is often mistaken for dementia or depression. A loved one might say, ‘Grandma’s just getting forgetful,’ when in reality, she’s reacting to a new pain pill. Providers often miss it because they’re focused on pain scores, not cognitive changes. But in older adults, confusion isn’t a normal part of aging-it’s a warning sign.

And it’s not just dementia patients. Anyone over 70 taking opioids long-term has a higher chance of developing delirium. The risk is highest in the first few days after starting the drug, or after a dose increase. That’s when you need to watch closest.

Dose Adjustments: The ‘Start Low, Go Slow’ Rule

There’s no such thing as a ‘standard’ opioid dose for older adults. The rule is simple: start low, go slow.

That means starting with 25% to 50% of the dose you’d give a younger adult. For example, if a typical starting dose for oxycodone is 5 mg every 6 hours, an older adult might start at 1.25 to 2.5 mg every 8 hours. And wait. Wait at least 3-5 days before increasing it. And if there’s any drowsiness, dizziness, or confusion-even mild-stop increasing and reassess.

Many doctors still prescribe the same doses they’d use for a 30-year-old. That’s outdated. And dangerous. A 2022 review found that nearly 60% of older adults on opioids were prescribed doses that exceeded geriatric safety guidelines.

It’s not just about the dose-it’s about the drug. Avoid long-acting opioids like fentanyl patches or extended-release oxycodone unless absolutely necessary. They’re harder to adjust and more likely to cause buildup. Short-acting options like immediate-release hydrocodone or morphine are easier to monitor and taper.

And don’t forget drug interactions. Opioids mixed with benzodiazepines, sleep aids, antihistamines, or even some antibiotics can turn dangerous. A simple cold medicine with diphenhydramine can double sedation. Always check the full medication list-not just the pain pills.

When to Stop: Deprescribing Is Not Giving Up

Many older adults stay on opioids for years-even when they’re not helping. Why? Because stopping feels scary. Patients worry about rebound pain. Doctors worry about withdrawal. But the truth? Long-term opioid use for chronic pain often doesn’t improve function or quality of life. And the risks keep growing.

Deprescribing isn’t about taking away comfort. It’s about replacing a risky solution with safer ones. The STOPPFall tool helps doctors decide when to reduce or stop opioids in people who’ve fallen or are at risk. It’s not a checklist-it’s a conversation starter.

Here’s how to approach it:

1. Ask: Is the opioid still helping? Is pain down? Can they walk better? Sleep better?
2. Check: Are they dizzy? Confused? Falling? Sleeping too much?
3. Try reducing by 10-25% every 1-2 weeks. Monitor closely.
4. Replace with non-drug options: physical therapy, heat/cold packs, acupuncture, or cognitive behavioral therapy for pain.
5. Don’t stop cold turkey. Even a few weeks of opioid use can cause physical dependence. Withdrawal can include anxiety, sweating, nausea, and insomnia.

Many patients improve after tapering. Their balance gets better. Their mind clears. They sleep better. And yes-they still have pain. But it’s manageable without the danger.

What Patients and Families Need to Know

Most older adults don’t know opioids can cause falls or delirium. They think it’s just ‘a pain pill.’ They don’t realize that confusion isn’t normal aging. They don’t know that physical dependence isn’t addiction.

Families should ask three simple questions:

• Why was this opioid prescribed?
• Is there a non-opioid option we could try first?
• What signs should we watch for-like dizziness, confusion, or trouble walking?

If your loved one is on opioids and has fallen, become confused, or seems ‘off,’ talk to the doctor immediately. Don’t wait for the next appointment. Bring a list of all medications, including over-the-counter ones. Ask if the dose is appropriate for their age and weight.

And remember: pain matters. But safety matters more. A person who can’t walk because of dizziness from an opioid isn’t better off than someone with moderate pain who’s stable and alert.

The Bigger Picture: Better Pain Management Is Possible

The good news? We’re starting to change. The CDC, FDA, and geriatric societies now strongly recommend avoiding opioids as first-line treatment for chronic pain in older adults. Non-drug therapies-physical therapy, tai chi, massage, nerve blocks, and even mindfulness-are proven to help with pain without the risks.

And tools like STOPPFall and START/STOPP guidelines are now being used in clinics to help doctors make smarter choices. More training is happening. More awareness is growing.

But progress is slow. Too many older adults are still getting prescriptions that don’t match their needs. Too many families are unaware of the risks. Too many doctors are still using old habits.

The goal isn’t to eliminate opioids entirely. It’s to use them wisely-only when the benefit clearly outweighs the risk. And for most older adults with chronic pain, that bar is much higher than most realize.