J American Geriatrics Society - 2025 - Marmor - Vestibular Suppressant Utilization and Subsequent Falls Among Patients 65

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Journal of the American Geriatrics Society, 2025; 73:1398–1405
https://doi.org/10.1111/jgs.19377
1398
Journal of the 
American Geriatrics Society
Journal of the American Geriatrics Society
CLINICAL INVESTIGATION OPEN ACCESS
Vestibular Suppressant Utilization and Subsequent Falls 
Among Patients 65 Years and Older With Dizziness in the 
United States
Schelomo Marmor1,2,3 | Pinar Karaca- Mandic4 | Meredith E. Adams1
1Department of Otolaryngology—Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, USA | 2Department of Surgery, University 
of Minnesota, Minneapolis, Minnesota, USA | 3Core for Clinical Quality Outcomes Discovery and Evaluation (CQODE), University of Minnesota, 
Minneapolis, Minnesota, USA | 4Department of Finance, Carlson School of Management, University of Minnesota, Minneapolis, Minnesota, USA
Correspondence: Schelomo Marmor (marm0014@umn.edu)
Received: 23 August 2024 | Revised: 18 November 2024 | Accepted: 26 December 2024
Funding: This work was supported by The National Institute on Deafness and Other Communication Disorders (NIDCD) (Grant NIDCD R21 DC016359).
ABSTRACT
Background: Falls pose a significant public health threat to older adults. Due to potential fall risk, guidelines recommend 
against the routine prescription of several medications commonly used for vestibular suppression, including meclizine and 
benzodiazepines.
Aims: We aimed to determine the factors associated with vestibular suppressant utilization among patients with dizziness 
≥ 65 years of age and subsequent falls.
Methods and Results: A retrospective longitudinal database of US commercial insurance and Medicare beneficiaries was used 
to study medical claims data (January 1, 2006, through December 31, 2015). Of 190,348 individuals ≥ 65 years old who presented 
with dizziness, 60,658 (32%) filled a vestibular suppressant prescription (27% anti- emetics, 73% anxiolytics), of which 20,448 were 
women (34%) within a month after their dizziness diagnosis. Of those individuals using suppressants, 8% experienced a fall re-
sulting in a medical encounter within 60 days of filling the prescription. After adjusting for sociodemographics and comorbidity, 
individuals with dizziness who received vestibular suppressants were more likely to experience recorded fall incidents (hazard 
ratio (HR) 3.33, confidence interval (CI) 1.93–5.72, pinitial provider 
encounter. To select new presentations with consistent fol-
low- up, individuals had at least 365 days of continuous enroll-
ment before and after t0 and no dizziness/vestibular diagnoses 
prior to t0. We previously published a description of a large 
adult dizziness cohort from which older patients for this study 
were selected [13, 14]. Existing claims data 1 year prior to index 
date were used to assemble the Charlson Comorbidity Index 
(CCI) of 19 weighted condition categories [15–17]. Although 
care is restricted to that administered in OP and emergency 
department (ED) settings, we do not have the ability to explic-
itly exclude nursing home patients who received care in an OP 
or ED setting.
2.3 | Vestibular Suppressant Utilization and Falls 
Definitions
Vestibular suppressant use was defined as the first occur-
rence of a prescription within 30 days of a new dizziness di-
agnosis. See Table  1 for list of National Drug Codes (NDC) 
of medications selected and used to define vestibular sup-
pressant use based on major therapeutic drug classes of 
anti- emetics, including the antihistamine meclizine and mo-
tion sickness medications and anti- anxiety drugs, including 
Summary
• Key points
○ This study underscores the potential association 
between guideline discordant use of vestibular sup-
pressant utilization and the likelihood of experienc-
ing subsequent falls.
○ Of 190,348 individuals ≤ 65 years old who presented 
with dizziness, 60,658 (32%) filled a vestibular suppres-
sant prescription (27% anti- emetics, 73% anxiolytics).
○ Our findings may inform clinical practice and foster 
shared decision- making between clinicians and in-
dividuals grappling with dizziness.
• Why does this paper matter?
○ Falls pose a significant public health threat to older 
adults, leading to widespread disability, severe inju-
ries, and substantial healthcare expenditures.
○ This study serves as a foundation for future de- 
implementation efforts to engage healthcare pro-
viders and patients to optimize the use of vestibular 
suppressants while considering the broader spec-
trum of safety and care.
○ We anticipate that this research will foster informed 
discussions with patients regarding the potential det-
rimental consequences of vestibular suppressant use, 
ultimately improving patient care and outcomes.
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benzodiazepines. Cohort characteristics were compared using 
the crude odds ratios (ORs) for categorical variables. Dizziness 
diagnoses were categorized into six groups, as defined previ-
ously (Supplementary Table  S1) [13]. We assessed the distri-
bution of suppressants by diagnosis type. Falls were defined 
using an established fall identification algorithm comprised of 
E- codes (external site of injury codes for accidental falls) plus 
diagnosis codes for fractures, dislocations, sprains, intracra-
nial injuries, and contusions, as described previously [14]. The 
timeframe for capturing falls was within 12 months of dizzi-
ness diagnosis, with the outcome being the time of the first 
vestibular suppressant prescription on potential fall risk. All 
individuals included in the cohort had continuous insurance 
enrollment for at least 1 year following dizziness diagnosis 
and were alive for at least 1 year following dizziness diagnosis. 
We created two fall risk models with individual therapeutic 
classes (as shown in tables) as well as a model with a combined 
suppressant use category. Cox proportional hazard modeling 
was used to assess the time- dependent factors associated with 
vestibular suppressants and the factors associated with falls, 
controlling for patient characteristics. A significance level (α) 
of 0.05 was used for all analyses. Analyses were completed 
using SAS 9.4 (SAS Institute, Cary, NC).
3 | Results
3.1 | Population Characteristics by Vestibular 
Suppressant
Of 190,348 individuals aged 65 years or older who presented 
with dizziness, 60,658 (32%) filled a vestibular suppressant 
prescription within 30 days after their dizziness diagnosis. 
Of that 60,658, 27% (n = 16,159) obtained an anti- emetic pre-
scription, and the remainder (73%) obtained an anti- anxiety 
medication such as a benzodiazepine. Table  1 presents the 
characteristics of those who did and did not obtain vestibular 
TABLE 1 | Distribution of vestibular suppressant use over 12 months 
from time of dizziness presentation by diagnostic category among 
65+- year- olds (N = 190,348).
Non- 
vestibular 
suppressant 
users 
n = 129,690 
(68%)
Vestibular 
suppressant 
users 
n = 60,658 
(32%)
Age (years) n % n %
Crude 
OR (CI)
65–74 33,071 26 15,874 26 REF
75+ 96,619 75 44,784 74 0.96 
(0.94–0.99)
Insurance type
Commercial 41,385 32 15,945 26 0.75 
(0.74–0.77)
Managed care 88,305 68 44,713 74 REF
Sex
Female 72,756 56 40,210 66 1.54 
(1.51–1.57)
Male 56,934 44 20,448 34 REF
Race
Asian 4502 3 1995 3 0.98 
(0.92–1.03)
Black 17,055 13 8504 14 1.10 
(1.07–1.14)
Hispanic 8558 7 4912 8 1.26 
(1.22–1.32)
NH White 82,657 64 37,413 62 REF
Other 16,918 13 7834 13 1.02 
(0.99–1.05)
Charlson 
Comorbidity 
Index Score
0 32,090 25 12,825 21 REF
1 29,264 23 13,591 22 1.16 
(1.13–1.19)
2+ 68,336 53 34,242 56 1.26 
(1.22–1.28)
Falls within 
60 days
No 123,832 98 55,691 92 REF
Yes 3025 2 4967 8 3.68 
(3.51–3.85)
Site of first 
dizziness 
presentation
(Continues)
Non- 
vestibular 
suppressant 
users 
n = 129,690 
(68%)
Vestibular 
suppressant 
users 
n = 60,658 
(32%)
Age (years) n % n %
Crude 
OR (CI)
ED 29,305 23 18,152 30 1.49 
(1.45–1.52)
OP 100,385 77 42,506 70 REF
Therapeutic Class
H6J 
(anti- anxiety)
44,499 73
H2F 
(anti- emetic)
16,159 27
Abbreviation: NH: Non- Hispanic.
TABLE 1 | (Continued)
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suppressants. The factors associated with the receipt of vestib-
ular suppressants by adults with dizziness aged 65 and older 
included female sex (vs. males), race or ethnicity (individu-
als identified as Black or Hispanic vs. non- Hispanic White), 
higher comorbidity (Charlson Comorbidity Index Score of 2 
and 1 vs. 0) and presentation to an emergency department 
(ED) for first place of dizziness diagnosis (Table 2). Provision 
of vestibular suppressants by diagnosis type ranged from 30% 
of those given a symptomatic diagnosis of dizziness and gid-
diness, not otherwise specified (780.x) to 43% with BPPV and 
48% of those diagnosed with vestibular neuritis or labyrinthi-
tis. Further breakdown by diagnosis and by therapeutic class 
is found in Figure 1.
3.2 | Factors Associated With Falling
When adjusting for all other factors (Table 3), individuals with 
dizziness who filled a vestibular suppressant prescription of 
either therapeutic class were more likely to have a recorded fall 
encounter than those who did not fill a vestibular suppressant 
prescription (hazard ratio (HR) 2.17, confidence interval (CI) 
1.26–3.74 for anti- emetic (H6J) vs. no suppressants and HR 
4.13, CI 2.40–7.12 for anti- anxiety (H2F) vs. no suppressants). 
Other factors associated with falls in the adjusted Cox model 
included higher comorbidity score and ED visit as the site of 
first dizziness presentation vs. OP (HR 0.50, CI (0.47–0.54)).Individuals identified as Hispanic, Asian, or Black were sig-
nificantly less likely than non- Hispanic white individuals to 
have a recorded fall encounter after a vestibular suppressant 
prescription (Table 3).
4 | Discussion
Our study presents a novel exploration of vestibular suppressant 
use patterns among adults with dizziness aged 65 years and older 
in the United States, offering valuable insights into the associ-
ation between these medications and subsequent falls among 
patients with dizziness. We found that a substantial proportion 
(32%) of individuals aged 65 and older who sought medical at-
tention for dizziness filled a vestibular suppressant prescription 
within a month of their diagnosis. Of those prescribed vestibu-
lar suppressants, 26% were provided with an anti- emetic such 
as meclizine or dimenhydrinate, while the remaining 74% were 
prescribed an anxiolytic such as a benzodiazepine. We found 
that 8% of those individuals who received a vestibular sup-
pressant experienced a fall resulting in a medical encounter 
compared to 2% who did not receive a vestibular suppressant. 
After controlling for sociodemographics, comorbidity, and site 
of presentation, individuals with dizziness who filled vestibular 
suppressant prescriptions remained more likely than those who 
did not experience recorded fall incidents (hazard ratio (HR) 
2.17, confidence interval (CI) 1.26–3.74 for anti- emetic (H6J) 
vs. no suppressants and HR 4.13, CI 2.40–7.12 for anti- anxiety 
(H2F) vs. no suppressants). While both drug classes increased 
fall risk, the hazard ratio was higher for benzodiazepines than 
anti- emetics.
Most falls result from an interaction between individual char-
acteristics, such as higher comorbidity, that increases an indi-
vidual's propensity to fall, and acute mediating risk factors that 
provide the opportunity to fall [15, 16]. Increased fall risk has 
previously been reported among community- dwelling older 
women compared to men [16]. Dizziness is a well- documented 
risk factor for self- reported falls and falls with injury [17]. Adults 
aged 60 years or older who fall because of dizziness or loss of 
balance were observed to be more than twice as likely to be hos-
pitalized than if the fall occurred after slipping or tripping [5]. 
Others have also found that patient factors including acute and 
chronic illnesses, abnormalities of gait or balance, and medi-
cations can increase the risk of falls and hip fractures in older 
adults, especially in tertiary care academic medical centers, 
within 30 days after admission [13]. Our findings in this study 
illustrate an additional longer- term association between the 
use of vestibular suppressants and subsequent falls after either 
outpatient or emergency department dizziness presentations. 
Although the medications are typically intended to alleviate 
symptoms and patient suffering, individuals who received ves-
tibular suppressants were 3–4 times more likely to experience 
recorded fall incidents in comparison to their counterparts who 
did not receive such medications. Consistent with observations 
in general populations, factors such as higher comorbidity 
scores, age of 74 years or older, female sex, and white race were 
also identified as contributing to an elevated risk of falls in our 
cohort [17–20].
TABLE 2 | Factors associated with vestibular suppressant use over 
12 months from time of dizziness presentation among 65+- year- olds.
OR 95% CI
Age (years) 65–74 REF
75+ 0.93 0.91 0.95
Sex
Female 1.58 1.55 1.61
Male REF
Race
Asian 1.01 0.96 1.07
Black 1.03 1.00 1.06
Hispanic 1.24 1.19 1.29
NH White REF
Unknown 1.01 0.98 1.04
Charlson Comorbidity Index 
Score
0 REF
1 1.16 1.13 1.19
2+ 1.28 1.25 1.32
Site of first dizziness presentation
ED 1.48 1.44 1.51
OP REF
Abbreviation: NH: Non- Hispanic.
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Despite the availability of established guidelines like the AGS 
Beers Criteria for Potentially Inappropriate Medication (PIM) 
Use in Older Adults, which have been widely approved by cli-
nicians, educators, researchers, healthcare administrators, 
and regulators [5, 11, 18], the use of vestibular suppressants 
remains prevalent by healthcare providers in both ED and out-
patient settings. These criteria, initially implemented over a 
decade ago in 2011 and updated on a three- year cycle, aim to 
guide medication choices for adults aged 65 and older across 
various care settings, excluding hospice and palliative care. 
AGS cites moderate evidence in making a strong recommen-
dation against use of meclizine and benzodiazepines among 
older adults. The antihistamine meclizine is highly anticho-
linergic and cumulative exposure to anticholinergics is asso-
ciated with risk of falls, delirium, and dementia [21, 22]. Older 
adults have increased sensitivity to and decreased metabolism 
of benzodiazepines, and these drugs also carry risk of physical 
dependence, cognitive impairment, falls, and injuries [21, 22]. 
Despite these clear guidelines, frequent provision of vestibular 
suppressants to older adults persists in clinical practice [23]. 
We observed a higher (23.3%) prevalence of use of anxiolytics, 
comprised predominantly of benzodiazepines, in our cohort of 
dizziness patients, which even more strongly suggests a need 
for targeted interventions to align prescription practices with 
evidence- based recommendations. Additionally, we found 
that anxiolytics were more strongly associated with the haz-
ard of falling than anti- emetics (HR 4.13, CI 2.40–7.12 for H2F 
(anti- anxiety) vs. no suppressants; HR 2.17, confidence inter-
val (CI) 1.26–3.74 for H6J (anti- emetic) vs. no suppressants). 
Additional factors that emerged as being associated with the 
receipt of vestibular suppressants among older adults with 
dizziness in our cohort included female sex, higher comorbid-
ity, Black race, Hispanic ethnicity, and dizziness evaluation 
in the outpatient setting. These factors will be pertinent when 
designing efforts to decrease inappropriate use.
As there are instances when symptomatic treatment with ves-
tibular suppressants is helpful, we likely observed a mix of ap-
propriate and inappropriate prescribing in our cohort. In the 
first several days of an acute vestibular crisis, as results from 
vestibular neuritis or labyrinthitis, patients can experience 
debilitating spontaneous vertigo that improves as vestibular 
FIGURE 1 | Distribution of vestibular suppressant use within 1 month from time of dizziness presentation by diagnostic category among 
65+- year- olds (N = 190,348).
70
64
60
65
57
52
21
28
31
21
36
41
9
8
9
13
7
7
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Dizziness and Giddiness (NOS)
central ver�go
Other peripheral verigo, labryrinthine disorders
Meniere's disease
BPPV
Ves�bular Neuri�s, labyrinthi�s
No suppresant H2F (an�axiety) H6J (anteme�c)
Ménière's disease
TABLE 3 | Cox model of factors associated with falling among 
65+- year- olds with dizziness diagnoses.
HR 95% CI p
Age (Years)
65–74 REF
75+ 1.04 (0.97–1.15) 0.20
Sex
Female 0.95 (0.89–1.03) 0.06
Male REF
Race
Asian 0.55 (0.49–0.67)(1.26–3.74) 0.01
aOverall hazard ratio (HR) 3.33, confidence interval (CI) 1.93–5.72, pAdams reported receiving grants from the National Institutes of 
Health/National Institute on Deafness and Other Communication 
Disorders (NIH/NIDCD) during the conduct of the study; grants from 
the NIH/National Institute of Neurological Disorders and Stroke, the 
US Department of Defense, NIH/NIDCD, Kellogg Charitable Trust, 
and Lions Hearing Foundation outside the submitted work. Dr. Adams 
served on a medical advisory council for Advanced Bionics, outside the 
submitted work. Dr. Karaca- Mandic reported receiving grants from the 
Agency for Healthcare Research and Quality, the American Cancer 
Society; personal fees from Sempre Health; and holding equity and an 
executive position in XanthosHealth outside the submitted work. Dr. 
Marmor reported receiving grants from the NIH during the conduct of 
the study.
Conflicts of Interest
The authors declare no conflicts of interest.
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https://doi.org/10.1177/1077558716656970
	Vestibular Suppressant Utilization and Subsequent Falls Among Patients 65 Years and Older With Dizziness in the United States
	ABSTRACT
	1   |   Introduction
	2   |   Materials and Methods
	2.1   |   Data Source
	2.2   |   Population
	2.3   |   Vestibular Suppressant Utilization and Falls Definitions
	3   |   Results
	3.1   |   Population Characteristics by Vestibular Suppressant
	3.2   |   Factors Associated With Falling
	4   |   Discussion
	5   |   Conclusion
	Author Contributions
	Acknowledgments
	Conflicts of Interest
	References