Cause for concern? Medications and falls in people living with cognitive impairment

The Bottom Line

  • Falls are a major public health concern associated with significant death and morbidity worldwide.  
  • Evidence on the link between cholinesterase inhibitors—medications used to prevent or delay cognitive impairment—and falls has been inconsistent. 
  • New research shows that these medications may reduce the risk for falls, increase the risk for fainting, and have no effect on the risk for fractures or accidental injury in people with cognitive impairments.
  • The use of cholinesterase inhibitors should be determined by a patient and their healthcare team after careful weighing of the potential benefits and harms. 

When we think of pressing public health problems, our minds often jump to topics like infectious diseases, tobacco use, obesity, and heart disease. Taking a tumble, while no laughing matter, is probably not on our radar. However, falls are considered a major issue across the globe, contributing to over 680,000 deaths annually from unintentional injury, only coming second to road traffic injuries. On top of that, over 37 million non-fatal falls require medical care every year, with some leading to disability or even the need for hospitalization or admission to a long-term care facility (1).

Age, underlying medical conditions, poor cognition, and medication side effects are some factors that increase the risk of experiencing falls (1). Folks living with Alzheimer’s disease and other types of dementia tick many of these boxes. Such neurocognitive disorders bring with them mild to severe cognitive impairment, so things like issues with memory, thinking, decision-making, and language.

To prevent or slow down the worsening of cognitive impairment, medications known as cholinesterase inhibitors—such as donepezil [Aricept®], rivastigmine [Exelon®, Prometax®], and galantamine [Razadyne®, Reminyl®]—are widely accessible and commonly used (2). That said, concerns around them being a risk factor for falls persist, as research findings have lacked consistency (2-5). To provide further clarity on the safety of these medications, a recent systematic review looked the effect of cholinesterase inhibitors on the risk for falls, fainting, and accidental injury in adults living with cognitive impairment, compared to placebo (2).

What the research tells us

It appears that cholinesterase inhibitors may reduce the risk for falls. Numbers wise, this means that in a group of 1000 people, approximately 10 fewer people fall. However, this positive result should be interpreted cautiously, because when we limit the analysis to studies of a higher quality, the effect on falls disappears. Second, use of these medications can increase the risk of fainting. Going back to the numbers, this means that in a group of 1000 people, four more people faint. Lastly, when it comes to the risk for fractures or accidental injury, we see no effect either way, meaning no increase or decrease in risk (2).  

Ultimately, decisions around whether a specific medication is right for someone living with cognitive impairment are made by the patient, caregivers, and their healthcare team. This is because the risks and benefits of using the medication will need to be weighed for each individual and their situation. The findings from this review can assist with this weighing process.   

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Author Details


  1. World Health Organization. Falls. [Internet] 2021. [cited January 2024]. Available from
  2. Ahuja M, Siddhpuria S, Karimi A, et al. Cholinesterase inhibitors and falls, syncope and injuries in patients with cognitive impairment: A systematic review and meta-analysis. Age Ageing. 2023; 52(11):afad205. doi: 10.1093/ageing/afad205.
  3. Renn BN, Asghar-Ali AA, Thielke S, et al.  A systematic review of practice guidelines and recommendations for discontinuation of cholinesterase inhibitors in dementia. Am J Geriatr Psychiatry. 2018; 26:134-147.
  4. Ali TB, Schleret TR, Reilly BM, et al. Adverse effects of cholinesterase inhibitors in dementia, according to the pharmacovigilance databases of the United-States and Canada. PLOS One. 2015; 10: e0144337.
  5. Ismail Z, Black SE, Camicioli R, et al. Recommendations of the 5th Canadian consensus conference on the diagnosis and treatment of dementia. Alzheimers Dement. 2020; 16:1182-1195.

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