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

When a 78-year-old man falls in his kitchen and breaks his hip, doctors often look at slippery floors or poor lighting. But rarely do they ask: was he on opioids? The truth is, for older adults, opioids aren’t just painkillers-they’re fall triggers, confusion inducers, and silent killers. And too often, the doses prescribed are simply too high for their aging bodies.

Why Older Adults React Differently to Opioids

Your body changes as you age. Your kidneys slow down. Your liver processes drugs less efficiently. You lose muscle mass and gain fat. Your blood-brain barrier becomes more porous. These aren’t minor tweaks-they’re major shifts in how your body handles medicine.

For someone under 65, a 10 mg dose of oxycodone might be routine. For an 80-year-old with reduced kidney function? That same dose can cause dizziness, confusion, and a dangerous drop in blood pressure. Studies show older adults are more sensitive to opioids because their brains absorb more of the drug, and their bodies clear it slower. This isn’t about being weak-it’s about biology.

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 a system failing people who need pain relief but can’t safely handle standard doses.

Opioids and Falls: A Deadly Combination

Falls are the leading cause of injury-related death in older adults. And opioids make them far more likely.

Opioids don’t just dull pain-they dull your balance, your reflexes, and your awareness. They cause sedation. They trigger orthostatic hypotension (a sudden drop in blood pressure when standing). They blur vision and slow reaction time. Even weak opioids like tramadol can cause hyponatremia-low sodium levels-which leads to dizziness, confusion, and stumbling.

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. The difference wasn’t statistically significant, but the trend was clear: opioids increase fall risk. And when an older adult falls, the consequences are rarely minor. A broken hip often leads to surgery, hospitalization, loss of independence, and sometimes death.

The STOPPFall tool was created to help doctors decide when to stop-or never start-opioids in people at risk of falling. It’s not about denying pain relief. It’s about weighing: does the benefit of pain control outweigh the risk of a life-altering fall?

Delirium: The Hidden Danger

Delirium isn’t just forgetfulness. It’s sudden, severe confusion, disorientation, hallucinations, and agitation. It’s not dementia. It’s not depression. It’s a medical emergency-and opioids are a leading cause in older adults.

A landmark 2023 study from the Danish Dementia Research Centre followed 75,471 people over 65 with dementia. Of those, 31,619 were prescribed opioids. The results were shocking: those who started opioids had an elevenfold higher risk of dying within the first two weeks compared to those who weren’t prescribed them.

Why? Because opioids disrupt brain chemistry. In someone with dementia, even a small dose can push the brain into crisis mode. Sedation turns to confusion. Confusion turns to agitation. Agitation turns to withdrawal, dehydration, and organ failure.

Doctors often mistake opioid-induced delirium for worsening dementia. Families think Grandma is just “acting strange.” But it’s not aging. It’s a drug reaction. And it’s preventable.

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

There’s no one-size-fits-all dose for older adults. But there is one rule every doctor should follow: start low, go slow.

That means beginning with 25-50% of the dose you’d give a younger adult. For example, instead of 5 mg of oxycodone every 6 hours, start with 2.5 mg every 8 hours. Monitor for sedation, dizziness, or confusion for at least 48 hours before increasing.

The CDC and other guidelines now strongly recommend this approach. But many doctors still prescribe the same doses they’d use for a 40-year-old. Why? Because they’re not trained in geriatric pharmacology. Because they’re pressed for time. Because they think, “She’s in pain-she needs this.”

But here’s the hard truth: if opioids aren’t making daily life better-if they’re not helping someone walk to the bathroom, eat dinner, or sleep through the night-then they’re doing more harm than good.

When Opioids Are Necessary-and When They’re Not

This isn’t about banning opioids. It’s about using them wisely.

For someone recovering from hip surgery? A short course of low-dose opioids may be appropriate. For someone with chronic lower back pain that hasn’t improved in six months? Odds are, opioids aren’t helping-and they’re making things worse.

Non-drug options should always come first: physical therapy, heat/cold therapy, acupuncture, tai chi, cognitive behavioral therapy for pain. These work. They’re safe. And they don’t cause delirium or falls.

When opioids are truly needed, use the lowest effective dose for the shortest possible time. Avoid long-acting formulations unless absolutely necessary. Never combine opioids with benzodiazepines, sleep aids, or antihistamines-those combinations can be fatal.

The Communication Gap

Here’s the quiet crisis: older adults don’t know what they’re being told.

A study in JAMA Network Open found that nearly half of primary care doctors felt unprepared to help patients taper off opioids. Patients, meanwhile, were terrified of addiction-but unaware of physical dependence, delirium, or fall risk.

Doctors worry about sedation. Patients worry about being labeled an addict. Neither side is talking about the real dangers.

Trust is the key. If a patient doesn’t feel heard, they won’t admit they’re dizzy. They won’t say they’re seeing things. They’ll just stop taking the pills-or keep taking them, silently suffering.

The solution? Ask directly: “Have you felt dizzy when standing up?” “Have you been confused or seen things that aren’t there?” “Are you sleeping more than usual?” These questions save lives.

Deprescribing: It’s Not Giving Up-It’s Getting Better

Stopping opioids isn’t failure. It’s progress.

Physical dependence can develop in as little as a few days. Withdrawal symptoms-sweating, nausea, anxiety, insomnia-can be brutal. That’s why tapering must be slow and supervised.

A good plan: reduce the dose by 10-25% every 1-2 weeks. Watch for pain returning. Watch for withdrawal. Adjust as needed. Offer alternatives. Celebrate small wins: “You walked to the mailbox without help today.”

The START/STOPP criteria are clinical tools that help doctors decide which drugs to keep and which to stop. They’re not perfect-but they’re better than guessing.

The Bigger Picture

Between 2005 and 2014, emergency visits for opioid problems in older adults rose by 112%. Inpatient stays jumped 85%. That’s not a coincidence. That’s a pattern.

We prescribed opioids like candy. We ignored the science. We treated pain like a number on a scale, not a human experience.

Now we know better. We know that a 70-year-old with arthritis doesn’t need 10 mg of oxycodone. We know that a dementia patient on opioids is 11 times more likely to die in two weeks. We know that falls kill.

The path forward isn’t about more pills. It’s about better care. Slower dosing. Better communication. More physical therapy. More respect for the aging body.

Pain is real. But so are the risks. And for older adults, the safest choice isn’t always the strongest one.