Hypnotic-Induced Fall Risk Upon Awakening: A Network Meta-Analysis of Postural Stability Outcomes

Chronic insomnia affects 10% of adults, with hypnotic medications widely prescribed. Residual pharmacological effects upon awakening may affect postural stability, increasing fall risk. We used a Network Meta-Analysis (NMA) framework to compare the influence of hypnotic medications on posture upon awakening. A systematic review and frequentist random-effects NMA was conducted following the PRISMA guidelines and a pre-determined protocol. We searched PubMed, EMBASE, ClinicalTrials.gov, WHO-ICTRP for randomized controlled trials until 10/21/2025, documenting the effects of hypnotics on static (body sway) and dynamic (walking test) balance. Risk-of-bias and confidence in evidence were assessed with RoB2 and CINeMA. Of 4459 identified records, 23 studies were included in the review. Most in-label doses of hypnotics showed no significant impact on postural stability in the morning compared to placebo, except zopiclone 7.5 mg both at bedtime (Standardized Mean Difference-SMD = 0.22, 95% C.I.[0.22;0.1.24]) and middle-of-the-night awakening (SMD = 4.45, 95% C.I.[3.54;5.36]), while zolpidem 6.5 mg extended-release proved worse in the subset including older adults (SMD = 0.39, 95% C.I.[0.01;0.76]). Same applied to middle-of-the-night evaluations for zopiclone 7.5 mg (SMD = 0.98, 95% C.I.[0.07;1.90]), zolpidem 6.5 mg extended-release (SMD = 1.14, 95% C.I.[0.30;1.98]), and zolpidem 10 mg (SMD = 1.60, 95% C.I.[0.63;2.58]). Confidence in the evidence was mainly low/very-low. Most regulatory-approved hypnotics did not significantly impair postural balance at in-label doses. However, caution is warranted for longer-acting and high-doses, particularly in high fall-risk individuals, including older adults. Given the age-related decline in postural reflexes and heightened sensitivity to CNS depressants, lower doses and shorter half-life drugs should be preferred whenever hypnotic therapy is necessary. Future research is needed to explore dynamic balance further to optimize prescribing guidelines for fall prevention in vulnerable populations.