INTRODUCTION: In older adults, trazodone is frequently prescribed for anxiety and insomnia owing to its perceived greater tolerability in comparison with benzodiazepines. However, it may have hypotensive effects. AIM: The aim of this study is to investigate the effects of trazodone on orthostatic blood pressure (BP) response and risk of syncope and falls in hypertensive older adults. PATIENTS AND METHODS: A longitudinal observational study involving patients ≥ 75 years was conducted in two geriatric outpatient clinics in Florence, Italy. At baseline, participants underwent a 3-min active stand test, office BP measurement and home and ambulatory BP monitoring. At follow-up, syncope and falls were recorded. RESULTS: Among 123 participants (mean age 81 years, 59% female), 12 (10%) reported regular trazodone use. Trazodone users showed lower office diastolic BP (71.8 versus 80.1 mmHg, p = 0.042), a greater systolic and diastolic BP reduction immediately after standing (Δsystolic CONCLUSIONS: In older hypertensive outpatients, trazodone is associated with a greater orthostatic BP drop and may predispose them to an increased risk of syncope and falls.