Shaky balance can start with a pill, an ear crystal or your glasses

Key takeaways

• In 2017, 94% of Americans 65 and older took at least one drug linked to falls, up from 57% in 1999, a University at Buffalo team found²³.
• About 1 in 5 older adults living at home has a meaningful blood pressure drop when standing, which can feel like poor balance⁸⁹.
• The most common inner-ear cause of spinning, BPPV, often clears with a head-positioning maneuver; treating 1 to 3 people brings prompt relief to one, a national guideline says¹.
• In an Australian trial, single-lens distance glasses cut falls by 40% in active outdoor walkers, but people who rarely went out fell more outdoors¹⁰.
• Sudden loss of balance can be a stroke: the CDC says to call 911 right away for any B.E. F.A.S.T. warning sign¹¹.

In a study cited by the national guideline on vertigo, about 9% of older adults sent to a geriatric clinic turned out to have an inner-ear problem no one had diagnosed¹. Three in four of them had fallen in the previous three months¹.

The problem is benign paroxysmal positional vertigo, or BPPV. Tiny crystal fragments drift into the wrong part of the inner ear. Then rolling over in bed or looking up sets off a brief spin¹. It’s common, often missed and very treatable.

When balance slips, people tend to blame weak legs or age. Often the cause is quieter: a pill, a blood pressure dip when you stand, feet that can’t feel the floor, or glasses that blur the curb.

Our earlier articles covered how balance works and how to train it. This one covers the hidden causes a clinician can check, and the clues that point to each.

Nearly every older adult takes a drug that can affect balance

A team at the University at Buffalo studied government data on older Americans’ prescriptions. In 1999, 57% of adults 65 and older took at least one drug that raises fall risk. By 2017, 94% did²³. Over the same years, deaths from falls in older adults more than doubled².

The biggest drivers were blood pressure medicines and antidepressants². Those drugs treat real illness. The lead researcher, Amy Shaver, and her colleagues don’t argue that older adults should go without important medicines just because those drugs carry some fall risk². The goal is to weigh each one.

The CDC’s STEADI program, its fall-prevention toolkit for clinicians, flags these drug classes⁴:

• seizure medicines (anticonvulsants);
• antidepressants, including older tricyclics and SSRIs;
• antipsychotics;
• benzodiazepines, often used for anxiety or sleep;
• opioid pain relievers;
• prescription sleeping pills such as zolpidem, eszopiclone and zaleplon.

The CDC also asks clinicians to review antihistamines, muscle relaxants, medicines that affect blood pressure and anticholinergic drugs, which can blur vision⁴⁷. The common thread is side effects: dizziness, drowsiness, confusion, blurred vision or a blood pressure drop when you stand⁴.

The American Geriatrics Society keeps a widely used list of drugs older adults should often avoid, called the Beers Criteria. Its 2023 update added anticholinergic drugs to the warnings for people who have fallen or broken a bone⁵.

Drugstore products count, too. The CDC tells clinicians to review nonprescription medicines and herbal supplements along with prescriptions⁴. In ACP Internist, a publication of the American College of Physicians, geriatrician Elizabeth Eckstrom of Oregon Health & Science University urged doctors to flag risky store-bought combinations³. One example: acetaminophen paired with diphenhydramine, a sedating antihistamine³.

A medicine review works best as a team effort

Cutting back on fall-risk drugs is harder than it sounds. The STOP-FALLS trial, published in JAMA Network Open in July 2024, tested a low-touch approach in 18 primary care practices in Washington state¹³. It included 2,367 adults aged 60 and older and targeted five types of brain-active drugs, such as opioids, sleeping pills, muscle relaxants and older antihistamines¹³.

Patients in half the practices got mailed education, and their clinicians got drug advice through the electronic health record¹³. Over the study, falls that needed medical care were no lower than with usual care¹³. Only one drug group, older tricyclic antidepressants, was stopped more often¹³.

The lead researcher, Elizabeth Phelan, told ACP Internist that her health system added its own deprescribing alerts during the study, which made an effect harder to show³.

That trial tested a light-touch approach, so it can’t say how a fuller, face-to-face review would do. The CDC’s SAFE framework describes that kind of review, done with you⁶:

• Screen: Gather every prescription, nonprescription drug and supplement, plus alcohol and recreational drug use. Check for interactions, and adjust for age and kidney or liver function.
• Assess: Talk through your goals, the side effects you notice and non-drug options.
• Formulate: Decide together whether a drug can be stopped, switched, lowered or simplified, and plan how to watch for side effects.
• Educate: Explain each change and the reason for it.

Some medicines need to be lowered slowly, the CDC notes⁶. That’s one reason never to stop a medicine on your own. Bring the bottles to your pharmacist or prescriber and ask the questions in the checklist below.

A blood pressure dip on standing can feel like bad balance

For some people, blood pressure sags for a moment every time they stand up. Doctors call this orthostatic hypotension. The usual definition is a drop of at least 20 points in the top (systolic) number, or at least 10 points in the bottom (diastolic) number, after you stand⁸⁹.

In the Cardiovascular Health Study, researchers checked 5,201 adults 65 and older lying down and again after three minutes on their feet⁸. About 18% had the drop, and it grew more common with each older age group⁸.

People with the drop had about 50% higher odds of reporting frequent falls⁸. That study was a snapshot in time, so it shows a link, not proof that one caused the other.

A 2018 review pooled 20 studies of nearly 25,000 older adults living at home. It found the drop in about 22%, or roughly 1 in 5⁹. Results varied a lot between studies, and the reviewers found that methods for checking the drop differed widely⁹.

The clue is timing. The vertigo guideline notes that this kind of dizziness comes on as you move from lying or sitting to upright, not when you turn your head¹.

STEADI asks clinicians to measure blood pressure lying down and then standing⁷. If it drops, the CDC suggests reviewing medicines, setting the right blood pressure goal, drinking enough fluids, doing foot pumps (flexing your ankles before you rise) and considering compression stockings⁷.

A seated reading at a checkup won’t catch this. Ask for the lying-and-standing check by name.

Loose ear crystals cause the most common kind of spinning

Your inner ear holds tiny crystals called otoconia; our earlier balance article explains how they work. In BPPV, fragments break loose and float into one of the curved canals that sense head turns¹.

Then a simple move, such as rolling over in bed or tipping your head back to look up, sets off spinning. Each spell usually lasts a minute or less¹.

The American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) updated its BPPV guideline in 2017. Its key facts¹:

• No inner-ear balance problem is more common. Roughly 2.4% of people get BPPV in their lifetime, usually starting in their 40s, 50s or 60s.
• Among older patients seen for dizziness, 4 in 10 had it.
• It takes a toll in later life: falls, low mood and trouble with everyday tasks are all more common in older adults who have it.
• Most patients never get the fix. By the guideline’s estimate, just 1 or 2 in 10 who see a doctor for BPPV receive a repositioning maneuver.

In the Dix-Hallpike test, a clinician moves your head and body into set positions and watches your eyes for a telltale twitching pattern¹.

The fix is mechanical. In a canalith repositioning procedure, the best known being the Epley maneuver, a clinician guides your head through a series of positions so gravity moves the debris out of the canal¹.

The guideline gives this a strong recommendation, based on reviews of randomized trials¹. Only 1 to 3 people need the treatment for one to get prompt relief¹.

In one study, 86% of people whose only problem was BPPV said their symptoms were gone afterward. That fell to 37% among people who also had another inner-ear problem¹.

The main side effects are a brief return of spinning during the moves and some unsteadiness afterward, which can raise fall risk for a short time¹.

The guideline also advises against routine brain scans or balance testing when the signs fit BPPV¹. It advises against treating BPPV routinely with dizziness-suppressing pills such as antihistamines or benzodiazepines¹.

Some cases clear on their own, about 20% within a month and up to half within three months¹. Either way, clinicians should recheck you within a month¹. If spinning lingers, our article on when rehab is needed covers vestibular therapy.

Your feet and eyes feed your balance, too

Numb feet. People with diabetes, particularly those with nerve damage in the feet, may already walk less steadily and have a dulled sense of where their feet are, the vertigo guideline notes¹.

STEADI asks clinicians to check feet and footwear⁷. They’re told to teach about shoe fit, traction, insoles and heel height, and to refer to a podiatrist when needed⁷.

Multifocal glasses. Bifocals and progressive lenses put a reading zone at the bottom of the lens. When you glance down while walking outside, you look through that zone, and Eckstrom told ACP Internist it can keep you from seeing an uneven sidewalk or a curb³.

Researchers in Australia tested a simple swap in the VISIBLE trial, published in the BMJ in 2010¹⁰. They enrolled 606 people, average age 80, who wore multifocal glasses outdoors and had a higher fall risk.

Half got single-lens distance glasses, plus advice to wear them for walking outside and in unfamiliar places¹⁰. The rest got usual care.

Overall, falls dropped by 8%, a difference that could have been chance¹⁰. But among people who spent a lot of time outdoors, falls dropped by 40%¹⁰. Among people who rarely went out, falls outside the home rose¹⁰.

The lesson: a second pair can help an active walker, but it isn’t for everyone. The CDC asks clinicians to discuss single versus multifocal lenses, refer to an eye specialist when vision is poor and consider whether cataract surgery would help⁷.

Alcohol. Falls tied to alcohol among adults 65 and older rose 7.5% a year from 2011 to 2019, according to a 2023 analysis in Annals of Emergency Medicine reported by ACP Internist³. The CDC’s medicine review asks about alcohol use, too⁶. A later article covers alcohol and aging.

Hearing gets its own look in a later article on hearing and vision checks.

The hidden balance-breakers checklist

This is our own tool, built from the CDC and guideline sources above. Use it to prepare for a visit, not to diagnose yourself.

Possible cause	Clues you might notice	Who checks it	What can help
Medicines and supplements	Drowsy, foggy, dizzy or blurry after a new drug or dose4	Pharmacist or prescriber, using a full medicine review6	A plan to stop, switch, lower or simplify, made with your prescriber6
Blood pressure drop on standing	Dizzy as you get up, not when you turn your head1	Clinician measures pressure lying, then standing7	Medicine review, fluids, foot pumps, compression stockings7
BPPV (loose ear crystals)	Brief spins when you roll over in bed or look up1	A clinician who does the Dix-Hallpike test, or one they refer you to1	Repositioning maneuver; recheck within a month1
Numb feet or foot problems	Can’t feel the floor well; diabetes1	Clinician foot exam; podiatrist7	Better shoe fit, traction, insoles, lower heels7
Multifocal glasses or poor vision	Trips on curbs and steps outdoors310	Optometrist or ophthalmologist7	Single-lens distance pair for walking outside, if you’re active outdoors10; cataract check7
Alcohol	Unsteady after drinks3	You and your clinician6	Cutting back
Stroke	Sudden imbalance, vision trouble, face droop, arm weakness or slurred speech11	Emergency crew	Call 911 right away11

Questions to bring to your appointment:

1. Could any of my medicines, including ones I buy myself, be affecting my balance?⁴
2. Can you check my blood pressure lying down and then standing?⁷
3. I get dizzy when I turn in bed. Could it be BPPV, and can you test for it?¹
4. Would single-lens glasses for walking outside make sense for me?¹⁰
5. Should someone take a closer look at my feet or shoes?⁷

When unsteadiness is an emergency

Sudden loss of balance can be a stroke. The CDC now teaches the B.E. F.A.S.T. check¹¹:

• Balance: Is the person suddenly dizzy or off balance?
• Eyes: Do they suddenly have trouble seeing?
• Face: When they smile, does one side droop?
• Arms: When they raise both arms, does one drift down?
• Speech: Is their speech slurred or strange?
• Time: Call 911 right away if you notice any one of these signs.

Note the time the symptoms began, the CDC says, because it helps doctors choose treatment¹¹. Don’t drive yourself or have someone drive you. An ambulance crew can start care on the way¹¹.

The American Stroke Association adds that balance loss from a stroke may show up as an uneven walk or weakness or numbness in one leg¹². The vertigo guideline lists stroke and transient ischemic attacks, or mini-strokes, among the conditions that can mimic BPPV¹.

For unsteadiness that isn’t sudden, STEADI asks three questions: whether you’ve fallen in the past year, feel unsteady when standing or walking, or worry about falling. A yes to any one is a reason to ask your clinician for a fall-risk check⁷.

Finding the cause fits natural-health thinking

Natural health asks a good question: what’s causing this? Balance is a place where that question pays off.

For BPPV, the guideline favors repositioning over routine dizziness pills¹. The best-proven fix uses gravity and a series of head positions, with no drug at all¹.

Root-cause thinking also means looking hard at what’s already in the cabinet, including supplements and sleep aids⁴. That isn’t a case against medicine. The aim is the right drug at the right dose, decided with someone who sees your whole list.

What the evidence shows

Claim	What the research shows	Evidence level
A repositioning maneuver relieves BPPV	Strong guideline recommendation based on reviews of randomized trials; 1 to 3 treated per prompt recovery1	Strong evidence
Routine brain scans help diagnose typical BPPV	The guideline recommends against imaging when the signs fit BPPV1	Evidence says no, or unsafe
Mailed education plus clinician drug advice cuts falls	A large 2024 randomized trial found no drop in medically treated falls; the health system’s own deprescribing push may have blurred the comparison313	Evidence says no, or unsafe
Single-lens distance glasses cut falls in active outdoor walkers	40% fewer falls in one trial’s active subgroup10	Promising but early
Single-lens glasses help people who seldom go out	More outdoor falls in the same trial10	Evidence says no, or unsafe
A blood pressure drop on standing is tied to falls	About 50% higher odds of frequent falls in one snapshot study8	Promising but early

Questions readers ask

The bottom line

Balance training is still the foundation of fall prevention, but it can’t fix a pill that makes you drowsy, a blood pressure dip when you rise, loose crystals in your inner ear or bifocals that hide the curb. Each of those has a clue you can notice and a check a clinician can do.

Bring your full medicine list, ask for a lying-and-standing blood pressure check, and mention any spins when you roll over in bed. And if your balance goes suddenly, or you notice sudden changes in vision, face, arm strength or speech, call 911.

Related reading

• Balance fades after 50, and a 10-second test shows where you stand
• Balance training works best when it wobbles you, three hours a week
• Most back pain fades on its own, and dizziness and bladder leaks respond to rehab
• The sleep aid with the clearest warning is the drugstore antihistamine
• Why one pharmacist should see everything you take

Sources

1. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. “Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).” Otolaryngology–Head and Neck Surgery, 2017;156(3 Suppl):S1–S47 (copy hosted by the Royal College of Occupational Therapists). rcot.org
2. American Pharmacists Association. “More older adults are taking drugs that can lead to falls” (on Shaver AL, et al., Pharmacoepidemiology and Drug Safety, 2021). Press release, June 17, 2021. pharmacist.com
3. ACP Internist. “Age and the rising risk of falling.” American College of Physicians, January 2025. immattersacp.org
4. Centers for Disease Control and Prevention, STEADI. “Medications Linked to Falls.” Fact sheet, 2017. cdc.gov
5. University of Illinois Chicago College of Pharmacy, Drug Information Group. “A Summary of the 2023 American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in the Elderly” (on the American Geriatrics Society Beers Criteria Update Expert Panel, Journal of the American Geriatrics Society, 2023;71(7):2052–2081). September 2023. dig.pharmacy.uic.edu
6. Centers for Disease Control and Prevention, STEADI. “SAFE Medication Review Framework.” Fact sheet, 2017. cdc.gov
7. Centers for Disease Control and Prevention, STEADI. “Algorithm for Fall Risk Screening, Assessment, and Intervention” (CDC Stacks copy). stacks.cdc.gov
8. Rutan GH, Hermanson B, Bild DE, Kittner SJ, LaBaw F, Tell GS. “Orthostatic hypotension in older adults: The Cardiovascular Health Study.” Hypertension, 1992;19(6 Pt 1) (Cardiovascular Health Study abstract page). chs-nhlbi.org
9. Saedon NI, Tan MP, Frith J, Newman A. “The Prevalence of Orthostatic Hypotension: A Systematic Review and Meta-Analysis.” Journals of Gerontology: Series A, 2020;75(1):117–122 (published online 2018; University of Malaya repository record). eprints.um.edu.my
10. Haran MJ, Cameron ID, Ivers RQ, Simpson JM, Lee BB, Tanzer M, et al. “Effect on falls of providing single lens distance vision glasses to multifocal glasses wearers: VISIBLE randomised controlled trial.” BMJ, 2010;340:c2265. bmj.com
11. Centers for Disease Control and Prevention. “Signs and Symptoms of Stroke.” Updated May 19, 2026. cdc.gov
12. American Stroke Association. “B.E. F.A.S.T. Experience: Balance Loss.” American Heart Association, 2026. stroke.org
13. Phelan EA, Williamson BD, Balderson BH, et al. “Reducing Central Nervous System–Active Medications to Prevent Falls and Injuries Among Older Adults: A Cluster Randomized Clinical Trial.” JAMA Network Open, July 25, 2024;7(7):e2424234. pubmed.ncbi.nlm.nih.gov