In Beers Criteria guidance, at what threshold of concurrent CNS-active medications does the risk of falls and fractures notably increase?

• A. Two or more
• B. Three or more
• C. Four or more
• D. One or more

Answer: (B)

Beers Criteria guidance highlights that in older adults, the risk of falls and fractures rises with polypharmacy, especially when several central nervous system–active drugs are used together. Each CNS-active medication can cause sedation, dizziness, impaired coordination, cognitive slowing, or orthostatic hypotension. When three or more CNS-active medications are taken concurrently, these effects can compound, leading to a notably higher risk of falls and fractures than with fewer agents.

CNS-active drugs include benzodiazepines and other sedative-hypnotics, antidepressants with sedating or anticholinergic properties, antipsychotics, anticonvulsants with CNS effects, and opioids. In practice, this means carefully reviewing a patient’s complete med list, avoiding unnecessary duplication of CNS-active drug classes, and considering deprescribing or substituting safer alternatives whenever possible. Emphasize nonpharmacologic approaches for sleep, mood, pain, and anxiety, and use the lowest effective dose for the shortest duration if a CNS-active medication is truly needed.