Table: Some Drugs Particularly Likely to Cause Problems in Older People-Merck Manual Consumer Version

Some Drugs Particularly Likely to Cause Problems in Older People

Drug	Use	Problem
Alpha adrenergic blockers	To treat high blood pressure	These drugs should not be used to treat high blood pressure. Use of these drugs increases the risk of orthostatic hypotension (sudden decrease in blood pressure when a person stands up). These drugs can make it hard for women to hold their urine.
Alpha-adrenergic agonists	To treat high blood pressure	These drugs should usually not be used to treat high blood pressure unless other drugs have been ineffective. Use of these drugs may cause orthostatic hypotension and an abnormally slow heart rate and may slow brain function. Reserpine can contribute to erectile dysfunction (impotence).
	To relieve pain
	To treat abnormal heart rhythms
Antidepressants	To treat depression	These older antidepressants have strong anticholinergic effects.* They also increase risk of falls, constipation, dry mouth, excessive drowsiness, and abnormal heart rhythms.
Antihistamines	To relieve allergy or cold symptoms, or to aid sleep	Many nonprescription (over-the-counter) and prescription antihistamines have strong anticholinergic effects.* These antihistamines can cause drowsiness and confusion, and when used regularly, they can also cause constipation, dry mouth, and difficulty urinating. Antihistamines are commonly included in cough and cold preparations and in pain relievers for use at bedtime. When using these drugs as sleep aids, people may also develop a tolerance to their effects.
Antiparkinson drugs	To treat Parkinson disease	More effective drugs are available.
Antipsychotic drugs	To treat loss of contact with reality (psychosis) or, somewhat controversially, to treat behavioral disturbances in people with dementia Sometimes to treat nausea	Antipsychotic drugs can cause drowsiness, movement disorders (that resemble Parkinson disease), and uncontrollable facial twitches. Some of these drugs also have anticholinergic effects.* Some other side effects are potentially fatal. Antipsychotic drugs should be used only when a psychotic disorder is present and require that a doctor closely monitors the person. When given to people with dementia, antipsychotic drugs increase the risk of stroke and death.
	Sometimes to treat severe acid reflux, nausea, headache, or slowed stomach emptying in people who have diabetes	Parkinson disease
	To calm, to relieve anxiety, or to aid sleep	People may become dependent on these drugs, the drugs may become ineffective in helping people sleep, and people can overdose by taking even low doses of these drugs.
Benzodiazepines	To calm, to relieve anxiety, or to aid sleep	These drugs can cause drowsiness and loss of balance when a person is walking. The risk of falls and fractures is increased as is the risk of motor vehicle crashes. The effects of some of these drugs last a very long time (often more than several days) in older people.
	To aid sleep	The side effects of these drugs are similar to those of benzodiazepines. It is best to use these drugs only for short periods of time.
	To help control nighttime urination	hyponatremia
	To treat heart failure or abnormal heart rhythms(arrhythmias)
^†	To reduce the risk of blood clots or to improve blood flow
	To relieve abdominal cramps and pain	These drugs have strong anticholinergic effects* and frequently cause side effects in older people. Their usefulness—especially at the low doses tolerated by older people—is questionable.
	To dilate blood vessels	These drugs are not effective for people of any age.
Estrogens with or without progestins	To treat osteoporosis and help relieve menopausal symptoms, such as hot flashes, night sweats, and vaginal dryness.	Estrogens increase the risk of breast and uterine (endometrial) cancer and may increase the risk of stroke, heart attack, and dementia in older women. Vaginal estrogen products seem to be safe and effective to treat painful intercourse, urinary tract infections, and other vaginal symptoms.
Histamine-2 (H₂	To treat heartburn (acid reflux), indigestion, or ulcers	These drugs may worsen memory and thinking problems in people with cognitive impairment.
	To treat diabetes
	To treat constipation
	hypogonadism)
	To increase appetite and help regain lost weight
	To relieve muscle spasms	Most muscle relaxants have anticholinergic effects.* They also cause drowsiness and weakness and thus increase the risk of falls and fractures. The usefulness of all muscle relaxants at the low doses necessary to avoid side effects in older people is questionable. The risks likely outweigh the benefits.
	To decrease blood pressure
	To treat bladder infections
	To relieve pain and inflammation
Proton-pump inhibitors	To reduce stomach acid production and treat acid reflux and ulcers	Long-term use of proton-pump inhibitors increases the risk of severe diarrhea caused by Clostridioides difficile infection, bone loss and fractures, and vitamin B12 deficiency.
	To treat diabetes	The effects of chlorpropamide last a long time. In older people, these drugs can cause low blood sugar levels (hypoglycemia) for many hours. Chlorpropamide can also cause the kidneys to retain too much water, lowering the sodium level in the blood.
* Anticholinergic effects include confusion, blurred vision, constipation, dry mouth, light-headedness and loss of balance, and difficulty starting to urinate. ^† COX-2 inhibitors = coxibs; NSAIDs = nonsteroidal anti-inflammatory drugs. Adapted from The American Geriatrics Society 2019 Beers Criteria Update Expert Panel: American Geriatrics Society updated Beers Criteria^® for potentially inappropriate medication use in older adults. J Am Geriatr Soc 67(4):674-694, 2019. doi:10.1111/jgs.15767

Drug

Use

Problem

These drugs should not be used to treat high blood pressure.

Use of these drugs increases the risk of orthostatic hypotension (sudden decrease in blood pressure when a person stands up).

These drugs can make it hard for women to hold their urine.

Alpha-adrenergic agonists

To treat high blood pressure

These drugs should usually not be used to treat high blood pressure unless other drugs have been ineffective.

Use of these drugs may cause orthostatic hypotension and an abnormally slow heart rate and may slow brain function.

Reserpine can contribute to erectile dysfunction (impotence).

To relieve pain

To treat abnormal heart rhythms

Antidepressants

To treat depression

These older antidepressants have strong anticholinergic effects.* They also increase risk of falls, constipation, dry mouth, excessive drowsiness, and abnormal heart rhythms.

Antihistamines

To relieve allergy or cold symptoms, or to aid sleep

Many nonprescription (over-the-counter) and prescription antihistamines have strong anticholinergic effects.*

These antihistamines can cause drowsiness and confusion, and when used regularly, they can also cause constipation, dry mouth, and difficulty urinating.

Antihistamines are commonly included in cough and cold preparations and in pain relievers for use at bedtime.

When using these drugs as sleep aids, people may also develop a tolerance to their effects.

Antiparkinson drugs

To treat Parkinson disease

More effective drugs are available.

Antipsychotic drugs

To treat loss of contact with reality (psychosis) or, somewhat controversially, to treat behavioral disturbances in people with dementia

Sometimes to treat nausea

Antipsychotic drugs can cause drowsiness, movement disorders (that resemble Parkinson disease), and uncontrollable facial twitches. Some of these drugs also have anticholinergic effects.* Some other side effects are potentially fatal. Antipsychotic drugs should be used only when a psychotic disorder is present and require that a doctor closely monitors the person.

When given to people with dementia, antipsychotic drugs increase the risk of stroke and death.

Sometimes to treat severe acid reflux, nausea, headache, or slowed stomach emptying in people who have diabetes

Parkinson disease

To calm, to relieve anxiety, or to aid sleep

People may become dependent on these drugs, the drugs may become ineffective in helping people sleep, and people can overdose by taking even low doses of these drugs.

Benzodiazepines

To calm, to relieve anxiety, or to aid sleep

These drugs can cause drowsiness and loss of balance when a person is walking. The risk of falls and fractures is increased as is the risk of motor vehicle crashes.

The effects of some of these drugs last a very long time (often more than several days) in older people.

To aid sleep

The side effects of these drugs are similar to those of benzodiazepines. It is best to use these drugs only for short periods of time.

To help control nighttime urination

hyponatremia

To treat heart failure or abnormal heart rhythms(arrhythmias)

^†

To reduce the risk of blood clots or to improve blood flow

To relieve abdominal cramps and pain

These drugs have strong anticholinergic effects* and frequently cause side effects in older people. Their usefulness—especially at the low doses tolerated by older people—is questionable.

To dilate blood vessels

These drugs are not effective for people of any age.

Estrogens with or without progestins

To treat osteoporosis and help relieve menopausal symptoms, such as hot flashes, night sweats, and vaginal dryness.

Estrogens increase the risk of breast and uterine (endometrial) cancer and may increase the risk of stroke, heart attack, and dementia in older women. Vaginal estrogen products seem to be safe and effective to treat painful intercourse, urinary tract infections, and other vaginal symptoms.

Histamine-2 (H₂

To treat heartburn (acid reflux), indigestion, or ulcers

These drugs may worsen memory and thinking problems in people with cognitive impairment.

To treat diabetes

To treat constipation

hypogonadism)

To increase appetite and help regain lost weight

To relieve muscle spasms

Most muscle relaxants have anticholinergic effects.* They also cause drowsiness and weakness and thus increase the risk of falls and fractures. The usefulness of all muscle relaxants at the low doses necessary to avoid side effects in older people is questionable. The risks likely outweigh the benefits.

To decrease blood pressure

To treat bladder infections

To relieve pain and inflammation

Proton-pump inhibitors

To reduce stomach acid production and treat acid reflux and ulcers

Long-term use of proton-pump inhibitors increases the risk of severe diarrhea caused by Clostridioides difficile infection, bone loss and fractures, and vitamin B12 deficiency.

To treat diabetes

The effects of chlorpropamide last a long time. In older people, these drugs can cause low blood sugar levels (hypoglycemia) for many hours. Chlorpropamide can also cause the kidneys to retain too much water, lowering the sodium level in the blood.

* Anticholinergic effects include confusion, blurred vision, constipation, dry mouth, light-headedness and loss of balance, and difficulty starting to urinate.

^†

COX-2 inhibitors = coxibs; NSAIDs = nonsteroidal anti-inflammatory drugs.

Adapted from The American Geriatrics Society 2019 Beers Criteria Update Expert Panel: American Geriatrics Society updated Beers Criteria^® for potentially inappropriate medication use in older adults. J Am Geriatr Soc 67(4):674-694, 2019. doi:10.1111/jgs.15767