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

Why Opioids Are Riskier for Older Adults

Older adults don’t process opioids the same way younger people do. As we age, our kidneys and liver slow down. We lose muscle mass and gain more body fat. Our blood-brain barrier becomes more permeable. These changes mean that even small doses of opioids can build up in the body and hit the brain harder. What’s safe for a 40-year-old might be dangerous for a 75-year-old.

One in five older adults in the U.S. gets prescribed an opioid each year. But the risks? They’re not small. Emergency visits for opioid problems in people over 65 rose by more than 110% between 2005 and 2014. Hospital stays for the same reason jumped 85%. And for older adults with dementia, starting an opioid can be deadly-research shows an elevenfold increase in death risk within just two weeks of starting the drug.

Falls: The Silent Danger

Falls are the leading cause of injury and death in older adults. Opioids make them far more likely. How? Three main ways: sedation, dizziness, and low blood pressure when standing up (orthostatic hypotension). Even weak opioids like tramadol can cause hyponatremia-a drop in sodium levels-that leads to confusion, drowsiness, and loss of balance.

One study of 2,341 adults over 60 found that those taking opioids had a 6% fracture rate over 33 months, compared to 4% in those not taking them. That difference wasn’t quite statistically significant, but it’s still alarming. And when you add in other medications-like benzodiazepines or antidepressants-the risk multiplies. Drug interactions through liver enzymes CYP2D6 and CYP3A4 can turn a moderate dose into a dangerous one.

It’s not just about falling. It’s about what happens after. A hip fracture in an older adult often leads to long-term disability, nursing home placement, or death. Opioids don’t just cause falls-they can change the course of someone’s life.

Delirium: Confusion You Can’t Ignore

Delirium is sudden confusion, disorientation, and trouble paying attention. It’s common in older adults, especially those with dementia, but opioids are a major trigger. Many doctors mistake opioid-induced delirium for dementia worsening or depression. That’s dangerous because it leads to more opioids being prescribed instead of less.

A 2023 study of 75,000 Danes over 65 with dementia found that nearly half were prescribed opioids. Those who started opioids had an 11 times higher risk of dying in the first two weeks than those who didn’t. The drug wasn’t treating pain-it was accelerating decline.

Delirium from opioids isn’t always obvious. It might look like the person is just "being forgetful" or "not themselves." But it’s a medical emergency. It increases hospital stays, raises the chance of permanent cognitive decline, and makes recovery from illness much harder.

Dose Adjustments: Start Low, Go Slow

There’s no one-size-fits-all dose for older adults. The rule of thumb? Start at 25% to 50% of the dose you’d give a younger person. For example, if a typical starting dose of oxycodone for a 50-year-old is 5 mg every 6 hours, an older adult might start at 1.25 mg to 2.5 mg every 8 hours.

Wait at least 3 to 5 days before increasing the dose. Watch for signs of too much: drowsiness, slurred speech, slow breathing, unsteady walking, or confusion. If any of these show up, the dose is too high-don’t wait for a follow-up appointment. Call the doctor.

Long-acting opioids like extended-release morphine or fentanyl patches are especially risky. They release medication slowly, so even a small overdose can build up over days. Many experts recommend avoiding them entirely in older adults unless absolutely necessary-and even then, only with close monitoring.

When to Stop: The Art of Deprescribing

Just because an older adult has been on opioids for years doesn’t mean they should keep taking them. Physical dependence can develop in as little as a few days. Many patients don’t realize they’re dependent-they think they just need the drug for pain.

Deprescribing isn’t about taking away comfort. It’s about removing harm. The STOPPFall tool helps doctors decide when to reduce or stop opioids in people at risk of falling. It looks at fall history, mobility, cognitive status, and other meds. If opioids are causing more harm than benefit, it’s time to taper.

Tapering must be slow. Cut by 10% every 1 to 2 weeks. Watch for withdrawal: anxiety, sweating, nausea, or worse pain. Sometimes, switching to a different painkiller like acetaminophen or gabapentin helps. Non-drug options like physical therapy, heat, massage, or acupuncture often work better and safer.

What Doctors and Patients Don’t Talk About

There’s a big gap between what doctors worry about and what older adults worry about. Doctors fear falls, confusion, and breathing problems. Older adults? They’re scared of addiction. Many don’t know opioids can cause physical dependence without being addictive. They don’t realize their dizziness isn’t "just getting older." They think the drug is working because it dulls the pain-even if it’s making them too sleepy to walk safely.

Trust is everything. If a patient doesn’t feel heard, they won’t agree to stop. A good conversation says: "I see how much pain you’re in. I want to help you feel better without putting you at risk for falls or confusion. Let’s try something safer."

What You Can Do

• Ask your doctor: "Is this opioid really necessary? Are there safer options?"
• Review all meds: Bring every pill bottle to appointments-including supplements and over-the-counter drugs.
• Watch for changes: If you or a loved one starts acting confused, stumbling, or sleeping more than usual after a new opioid prescription, call the doctor right away.
• Push for non-drug options: Physical therapy, tai chi, cognitive behavioral therapy for pain, and even music therapy can reduce pain without side effects.
• Don’t stop suddenly: If you’ve been on opioids for more than a few weeks, stopping cold turkey can be dangerous. Always taper with medical supervision.

The Bigger Picture

The opioid crisis didn’t skip older adults. In fact, they’ve been hit hardest-and quietly. Their symptoms get blamed on aging. Their pain gets undertreated. Their dependence gets ignored. But we’re learning. Guidelines from the CDC and FDA now stress caution in older patients. Tools like STOPPFall and START/STOPP criteria are helping doctors make smarter choices.

The future isn’t more opioids. It’s better pain management: tailored, monitored, and safe. For older adults, that means less risk, more independence, and a real chance to live well-even with chronic pain.