One in four adults aged 65 and older falls each year in the United States. Most people assume the culprit is something physical: a loose rug, unsteady balance, a wet floor. But a large body of evidence now points to a factor that gets far less attention – a prescription written on the day a patient leaves the hospital.
The timing matters in a specific and measurable way. When an older adult who has never used sedative medications before is handed a new prescription at discharge, their risk of falling in the following 30 days rises sharply. The same prescription can also raise their odds of ending up back in the emergency department, being readmitted to the hospital, and even dying. These are not theoretical risks drawn from small studies. They emerge from one of the largest analyses of its kind ever conducted, tracking outcomes across two decades of real-world hospital discharges.
Among patients who received a new sedative at discharge, the risk was concentrated specifically in those with no prior history of using these drugs. Those who had been taking sedatives before admission did not face the same elevated hazard. That distinction has direct implications for how discharge prescribing should be approached, and when a family member should ask questions before a loved one fills a new prescription on the way home.
The Ontario Study Findings
Dr. Lisa D. Burry, Pharm.D., Ph.D., a Clinical Pharmacy Specialist at Mount Sinai Hospital and Associate Professor at the University of Toronto, and colleagues conducted a population-based cohort study involving older adults aged 66 years and older who were discharged alive from a hospital in Ontario between 2003 and 2023, examining the incidence and risk of adverse events associated with sedatives within 30 days after discharge. The study included more than 1.86 million adults aged 66 and older and aimed to understand prescribing patterns to inform discharge prescribing in the future. The results were published in June 2026 in the Canadian Medical Association Journal.
Among the 1,868,484 older adults studied, with a mean age of 77 years and 52.1% female, 13.2% filled a sedative prescription after discharge. Of these patients, 31.0% were sedative-naive before hospital admission. That last figure is critical: nearly one in three people who left the hospital with a sedative prescription had no recent history of using one. They were, by definition, the most vulnerable to its effects.
The risk of falls was 20% higher in people with a new sedative prescription, and the risk of an emergency department visit, readmission, and death within 30 days was also elevated. As Dr. Burry and her co-authors wrote, “our results showed that discharging older adults after an acute care hospital stay with a new prescription for these medications was associated with an increased hazard of falls requiring medical attention, further need for acute hospital care, and death in the 30 days after hospital discharge, whereas individuals with prior exposure did not experience the same increased hazards.”
The study design was observational, which means it demonstrates association rather than proving direct causation. Residual confounding – the possibility that sicker patients received more prescriptions and also had worse outcomes for unrelated reasons – cannot be entirely ruled out. Nonetheless, the size of the dataset and the 20-year timeframe give the findings considerable weight.
Why Sedative Medications Older Adults Receive at Discharge Are Different
Sedative medications – a category that includes benzodiazepines (drugs like lorazepam and clonazepam used for anxiety or insomnia), antipsychotics (such as quetiapine and haloperidol), and certain sedating antidepressants – are routinely prescribed in hospital settings to manage agitation, delirium, anxiety, and sleep disruption. The problem arises when those prescriptions follow a patient out the door.
In a hospital, a patient taking a sedative is monitored. Staff are present if they become unsteady or confused. At home, the same drug in the same dose reaches a body that is now unsupported, often moving through unfamiliar physical spaces after a period of illness-related deconditioning. The pharmacological effect hasn’t changed; the environment has.
Not all sedative classes carry the same profile of risk. The CMAJ study found that older adults discharged with a new prescription for a benzodiazepine or antipsychotic were at particular risk for falls and other negative consequences. The American Geriatrics Society’s Beers Criteria, a widely used clinical guideline for appropriate prescribing in older patients, explicitly recommends “avoiding benzodiazepines – all short-, intermediate-, and long-acting forms – for all older adults,” citing increased risks of cognitive impairment, delirium, falls, and fractures.
A 2025 study from the University of Tennessee quantified the fall risk from antipsychotics specifically, finding that atypical antipsychotics – the newer generation that includes quetiapine, risperidone, and olanzapine – increase fall risk by 72% in older adults, while the older “typical” antipsychotics increase fall risk by 48%. These are not marginal elevations.
Why Antipsychotic Use Is Rising Despite the Risks
Against this backdrop, antipsychotic prescribing among older Americans has moved sharply in the wrong direction. A research letter by investigators from Columbia University and Rutgers University, published in JAMA Psychiatry, tracked antipsychotic use among adults 65 and older from 2015 through 2024 using a national prescription-claims database that captures more than 90% of retail pharmacy fills. They found that the annual rate of any antipsychotic use increased nearly 52% to 4.05 per 100 older adults over that period, and that long-term use – defined as at least 120 days a year – rose 65%, reaching 2.45 per 100 older adults.
Rates were highest among people 75 and older, rising from 3.42 to 5.12 per 100. This is precisely the group with the greatest physiological vulnerability to fall-related injury. The trend is notable because antipsychotics have limited proven effectiveness in people 65 and older and carry serious documented risks, including falls, fractures, cardiovascular events, pulmonary embolism, and death.
The FDA’s concern about antipsychotic use in elderly patients is not new. The agency issued a black-box warning – the strongest safety alert available on a drug label – for all second-generation antipsychotic medications about increased risk of death in elderly patients with dementia-related psychosis. That warning has been in place since 2005. Yet prescriptions have continued to climb.
Among patients who took an antipsychotic in a given year, the share with at least one prescription from a psychiatrist fell from 30% in 2015 to 20% in 2024. Over the same period, the share who filled an antipsychotic from a pharmacy in a long-term care facility rose from 14% to 21%. The shift suggests that antipsychotics are increasingly being managed by non-specialist prescribers in institutional settings, where behavioral symptoms of dementia may be driving prescriptions in lieu of more labor-intensive non-pharmacological alternatives.
“The evidence is pretty solid on the risks,” said Stephen Crystal, co-author of the JAMA Psychiatry letter and director of the Center for Health Services Research at the Rutgers Institute for Health, Health Care Policy and Aging Research.
Which Sedatives Are Safer
One clinically relevant distinction that emerged from the CMAJ research involves antidepressants that have sedating properties. While benzodiazepines and antipsychotics were both consistently associated with elevated risk, the picture for sedating antidepressants was more varied.
Trazodone, a sedating antidepressant commonly prescribed for insomnia in older adults, has a meaningfully different risk profile than antipsychotics. A 2018 study published in the Journal of the American Geriatrics Society found that “use of trazodone was associated with a safer alternative to atypical antipsychotics” in dementia patients – a finding that has influenced clinical guidance toward trazodone when sedation is genuinely necessary in this population.
Mirtazapine, another sedating antidepressant sometimes used for sleep, anxiety, or appetite stimulation in older adults, carries a different concern. A 2025 study published in BMC Geriatrics found that “incident mirtazapine use was associated with a 16% higher risk of all-cause mortality compared to sertraline” in long-term care residents. That comparison is relevant because mirtazapine is sometimes chosen for its sedating properties without full appreciation of its mortality signal relative to other options.
The risk profile differs by drug class, dose, and patient context, and clinicians weighing sedative options at discharge need to account for those differences explicitly rather than treating all sedating medications as equivalent.
The Scale of the Fall Problem in the U.S.
Falls are the leading cause of fatal and non-fatal injuries among older adults, with 14 million Americans aged 65 and older – one in four – falling each year, according to the National Council on Aging. The estimated annual average inpatient cost per fall injury is $18,658. Across the entire older adult population, data published in 2024 shows that healthcare spending for non-fatal falls among older adults reached $80 billion in 2022. Against that backdrop, a 20% increase in fall risk attributable to a single prescribing event at discharge represents a potentially preventable driver of an already enormous burden.
For readers who want to understand how specific sleep medications – including commonly prescribed antipsychotics used off-label for insomnia – contribute to this risk, this breakdown of quetiapine’s documented effects in older adults covers the trial data in detail.
Deprescribing as a Clinical Strategy: What the Evidence Shows
If initiating sedatives at discharge raises risk, stopping them reduces it – and by a substantial margin. A 2025 secondary analysis of the MedSafer randomized controlled trial, published in the Journal of the American Geriatrics Society, found that patients who had their sedatives deprescribed were 61% less likely than continued users to have a post-discharge adverse drug event, and new sedative use at discharge was associated with appreciable risk of falls.
The study included data from 3,360 hospitalized adults aged 65 and up who were taking more than five medications, with a median age of 78 years. Removing patients from sedatives did not worsen sleep issues within 30 days, and participants who stayed on sedatives after discharge or started them at discharge were least likely to have improved sleep outcomes. That last point addresses one of the most common justifications for continuing sedative prescriptions at discharge: that stopping them will cause worse sleep. The data does not support that concern, at least in the short term.
The CMAJ authors concluded that “clinicians must consider whether new sedative prescriptions are essential or can be deprescribed or de-escalated before or shortly after hospital discharge,” adding that when ongoing sedative use is required, community support such as falls or mobility assessments and ongoing medication reviews may help mitigate risks.
The MedSafer data also showed that the hospitalization itself may be the best available moment to act. As the authors of that analysis noted, “hospitalization likely represents a window of opportunity to improve care by promoting sedative deprescription and avoiding new starts.”
Read More: People With Sleep Problems May Experience Hidden Risks if They Are Taking Common Sleep Pill
What to Do With This Information
The combined weight of the 2026 CMAJ study, the MedSafer analysis, and the antipsychotic prescribing data from JAMA Psychiatry points to a consistent and actionable conclusion: sedative medications in older adults carry concentrated, quantifiable risk when started fresh at hospital discharge, and that risk is elevated precisely in patients who have no prior tolerance to the drugs.
For patients and families, the most immediately useful action is to ask a direct question before filling any new sedative prescription after a hospital stay: was this medication started in the hospital, and is it intended as a short-term measure or a long-term one? If the answer involves any uncertainty, requesting a pharmacist-led medication review or a conversation with a geriatrician before filling is reasonable and evidence-supported.
For clinicians, the data support treating hospital discharge as an active deprescribing opportunity rather than a passive prescription-continuation event. The 61% reduction in adverse drug events seen in patients who were deprescribed at discharge is among the strongest pharmacological intervention signals in recent geriatric literature. The first question at discharge, particularly for any patient new to sedatives, should be whether the prescription needs to leave the building at all.
Disclaimer: The author is not a licensed medical professional. The information provided is for general informational and educational purposes only and is based on research from publicly available, reputable sources. It is not intended to constitute, and should not be relied upon as, medical advice, diagnosis, or treatment. Always consult a licensed physician or other qualified healthcare provider regarding any medical condition, symptoms, or medications. Do not disregard, avoid, or delay seeking professional medical advice or treatment because of information contained herein.
AI Disclaimer: This article was created with the assistance of AI tools and reviewed by a human editor.