As you get older, medications can start affecting you differently. In particular, you may be more sensitive to side effects. And certain side effects — like confusion, low blood pressure, and falls — can be especially risky in the elderly.
In fact, the American Geriatrics Society has created a list of medications that should be avoided for this reason. But if you need to take them, you may need to use extra caution.
So, which medications have made the list? And what should you do if you’re taking one? While it’s not a complete list, below we discuss important ones you should know and safer alternatives to consider.
1. Benadryl and older antihistamines
Antihistamines are used for various conditions, including allergies and sleep problems. But first-generation antihistamines should be avoided in older adults in many cases.
Because as we age, it’s harder for our bodies to properly get rid of them. And higher doses may be needed for them to work. That can greatly raise your risk of side effects, including confusion. Other problematic antihistamine side effects in older adults include constipation and dry mouth.
Diphenhydramine (Benadryl) is well-known for causing side effects in the elderly. But other examples include:
Doxylamine (Unisom)
Chlorpheniramine (Chlor-Trimeton)
Dimenhydrinate (Dramamine)
What’s more, these antihistamines may interact with other medications you’re taking. For example, Benadryl can interact with several medications, including metoprolol (Lopressor, Toprol XL).
Better options: Try newer antihistamines for allergy symptoms. Examples include cetirizine (Zyrtec), fexofenadine (Allegra), or loratadine (Claritin). If you have trouble sleeping, it’s best to talk to your healthcare provider.
2. Sleep medications
Insomnia is often treated with prescription medications known as “Z-drugs.” These include eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien). But in older adults, they can cause serious problems. Delirium, falls, and cognitive problems are just a few examples.
Benzodiazepines (BZDs) should also be avoided for sleep problems. These include medications like estazolam, triazolam (Halcion), and temazepam (Restoril). They have the same risks as Z-drugs for older people.
There are other BZDs available approved for uses beyond sleep. Examples include alprazolam (Xanax), lorazepam (Ativan), and clonazepam (Klonopin). You may be taking one that’s appropriate for a different health condition (e.g., seizures, anxiety). In this case, the benefits may outweigh the risks of treatment.
Better options: Focus on non-pharmacologic treatment of insomnia by using good sleep hygiene, like setting a consistent bedtime.
3. Muscle relaxers
Muscle relaxers can be difficult for older adults to tolerate due to side effects. In particular, they can make you feel sleepy and confused, putting you at risk of falls. And they can cause constipation and urination problems, too.
Carisoprodol (Soma), cyclobenzaprine, and methocarbamol are a few common examples.
Better options: Try exercise and supportive treatments in place of muscle relaxers. Ask your healthcare provider about alternative options that may be safer for you.
4. Antispasmodics
Spasms in your digestive tract can be quite a pain. Sometimes, they’re treated with antispasmodics, like dicyclomine and hyoscyamine (Levsin).
But these medications may not work very well if you’re older. And they can cause side effects like confusion, dry mouth, and constipation, too. That’s why they’re typically avoided in older people.
Better options: If you have abdominal pain, it’s best to discuss treatment options with your healthcare provider.
5. Seroquel and other antipsychotic medications
Antipsychotic medications are used for mental health conditions like schizophrenia and bipolar disorder. A few examples include aripiprazole (Abilify), quetiapine (Seroquel), and risperidone (Risperdal). Seroquel is also sometimes prescribed off-label for sleep in older adults.
Antipsychotic medications can cause a number of concerning side effects in older adults. Examples include confusion, dizziness, and low blood pressure. Uncontrollable body movements and urination problems are also possible. But, they may still be used with caution for certain uses.
These medications have also been used to treat behavioral problems in older people with dementia. But, this has been shown to raise the risk of death and stroke. The FDA has issued its strictest warning to avoid them for this use in older adults.
Better options: Antipsychotic medications may be appropriate for schizophrenia and bipolar disorder. Non-medication treatments for dementia-related behavior problems should be tried before considering an antipsychotic.
6. Tricyclic antidepressants
Tricyclic antidepressants (TCAs) have mostly been replaced by newer classes of antidepressants. They’re known to cause confusion, low blood pressure, sedation, and other side effects. That’s why most older people should avoid them.
And TCAs aren’t just used for depression. Other uses include migraines, anxiety, and insomnia. Some common ones are amitriptyline, doxepin (Silenor), and nortriptyline (Pamelor).
Better options: Newer antidepressants can have the same risks, but they’re generally lower than TCAs. Selective serotonin reuptake inhibitors (SSRIs) are one example.
7. Barbiturates
Barbiturates, like phenobarbital, can be used to treat epilepsy or help with sleep. Some, like butalbital, are combined with other medications for pain or migraines. Those include Fioricet (butalbital/acetaminophen/caffeine) and Fiorinal (butalbital/aspirin/caffeine).
Older people should generally avoid these medications. Besides causing confusion, they can be habit-forming and pose a risk for overdose.
Better options: Alternatives for epilepsy include lacosamide (Vimpat), lamotrigine (Lamictal), and levetiracetam (Keppra). It’s best to discuss your options with your healthcare provider. And instead of taking butalbital for pain, ask them about safer alternatives.
8. Indomethacin
Indomethacin (Indocin) is a nonsteroidal anti-inflammatory (NSAID). It's sometimes used for arthritis pain and gout. But it may cause confusion in older people. What’s more, serious kidney damage and gastrointestinal ulcers are also possible.
Better options: Typically, older adults should avoid taking NSAIDs beyond short-term, occasional use. Your healthcare can determine if there are safer NSAID options for you and how long you can take them.
9. Opioids
Opioid pain medications commonly cause confusion and drowsiness in older adults. Constipation, urination problems, and slowed breathing are also possible.
Meperidine is one opioid that should be avoided in older adults. That’s because it may be more likely to cause confusion. And it may not offer much of a benefit, either.
It’s recommended to avoid combining other opioids with certain medications. Examples include BZDs, gabapentin (Neurontin), and pregabalin (Lyrica). These combinations can raise the risk of severe side effects and death.
Better options: Your healthcare provider may try non-opioid options to treat your pain. But for some people, an opioid may be necessary. Your provider can help you figure out which treatment is right for you and how to safely manage these risks.
10. Alpha blockers
Some alpha blockers can be used to treat high blood pressure (hypertension). Examples include doxazosin (Cardura), terazosin, and prazosin (Minipress). They work by relaxing your blood vessels, which helps lower your blood pressure.
But this effect can result in orthostatic hypotension. This is when your blood pressure drops as you’re changing positions (e.g., from sitting to standing). Orthostatic hypotension is especially risky in older adults. That’s because it can raise your risk of fainting and falling.
For this reason, your healthcare provider will likely avoid prescribing an alpha blocker to lower your blood pressure.
Better options: Your healthcare provider may choose a different medication. Examples include thiazide diuretics, angiotensin-converting enzyme (ACE) inhibitors, or calcium channel blockers.
11. Long-acting sulfonylureas
Glimepiride (Amaryl) or glyburide (Diabeta) are used to help control blood sugar in Type 2 diabetes. They both belong to a medication class called sulfonylureas. But they tend to stick around in your body longer than other sulfonylureas.
The most common side effect of sulfonylureas is low blood sugar (hypoglycemia). This risk may be more severe and last longer with glimepiride and glyburide. If left untreated, it can be life-threatening.
Better options: Glipizide (Glucotrol) is a shorter-acting sulfonylurea that may be a better option. There are other medications with minimal hypoglycemia risks, too. Examples include metformin and glucagon-like peptide-1 (GLP-1) agonists.
Choosing a safer alternative medication
In some cases, there may be safer options for older adults. For example, alternatives to Benadryl in the elderly include second-generation antihistamines, like Claritin.
There are also many antidepressant, blood pressure, and epilepsy medications that are less risky in this age group. Your healthcare provider can help you find out which medication is best for your situation.
If you’re concerned about taking a medication on this list, talk to your healthcare provider. It’s possible that the medication’s benefits outweigh the risks for you. If this is the case, you and your provider may need to watch your health more closely. Don’t stop taking a medication without letting them know first.
The bottom line
As you age, some medications may no longer be appropriate for you. Usually, it’s because you may be more sensitive to side effects. Confusion, low blood pressure, and falls can be riskier in this age group.
If you’re age 65 years or older, now is the time to review your medications. Talk to your healthcare provider about your options, which may include safer choices. But never stop or change your medications without talking to them first.
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