Medications That Are High-Risk for Seniors: What to Review

Every year, tens of thousands of seniors end up in the hospital-not because of a fall, stroke, or heart attack-but because of a medication they were told was safe. It’s not rare. It’s not an accident. It’s a pattern. And it’s entirely preventable.

Why Seniors Are More Vulnerable to Medication Risks

As we age, our bodies change. The liver doesn’t process drugs as quickly. The kidneys filter less efficiently. Body fat increases, muscle mass declines, and brain sensitivity to certain chemicals goes up. What was a harmless dose at 45 can become dangerous at 75.

The American Geriatrics Society (AGS) has spent decades tracking which medications cause the most harm in older adults. Their Beers Criteria, updated in May 2023, is the gold standard. It’s not a list of banned drugs-it’s a warning system. These are medications that, for most seniors, carry more risk than benefit.

According to the CDC, nearly 40% of adults over 65 take five or more prescription drugs at once. That’s called polypharmacy. And with each added pill, the chance of a bad reaction climbs. One study found that seniors on four or more medications are twice as likely to be hospitalized for a drug-related problem.

The Top 5 High-Risk Medications for Seniors

Not all risky drugs are obvious. Some are still prescribed because they’re cheap, familiar, or have been used for decades. Here are the five that need the most attention:

• Zolpidem (Ambien®) - This sleep aid doesn’t just make you drowsy. It lingers in the body of older adults, causing confusion, sleepwalking, and falls. Studies show it increases hip fracture risk by 2.5 times. The AGS says it should be avoided entirely for chronic use in seniors. Safer alternatives? Trazodone or cognitive behavioral therapy for insomnia (CBT-I).
• Glyburide (Diabeta®) - A diabetes drug that can drop blood sugar too low. In seniors, this isn’t just a scare-it’s life-threatening. Glyburide causes hypoglycemia in nearly 30% of elderly patients, leading to emergency visits. Glipizide or metformin are far safer choices with lower risk of crashes.
• Diphenhydramine (Benadryl®) - Found in allergy pills, sleep aids, and even some cold medicines, this antihistamine has a high anticholinergic score. Long-term use increases dementia risk by 54%. It also causes dry mouth, constipation, blurred vision, and urinary retention. For allergies, loratadine (Claritin) or cetirizine (Zyrtec) are better. For sleep, skip it entirely.
• Promethazine (Phenergan®) - Often given for nausea or vomiting, this drug can trigger severe muscle spasms, tremors, and even seizures in older adults, especially those with Parkinson’s. One study showed it doubles seizure risk in seniors with epilepsy. Ondansetron (Zofran) is a much safer option for nausea.
• Nitrofurantoin (Macrobid®) - Used for urinary tract infections, this drug can cause deadly lung damage in seniors with reduced kidney function. The risk spikes when creatinine clearance drops below 60 mL/min. For UTIs, amoxicillin or nitroxoline are safer if kidney function is low.

What You Might Not Realize: Hidden Risks in Everyday Pills

Many seniors don’t realize their daily pills are part of the problem. Over-the-counter meds, herbal supplements, and even cough syrups can pack a dangerous punch.

Take cough syrups with dextromethorphan and diphenhydramine. They’re sold as “natural sleep aids” or “cold relief.” But combined, they create a powerful anticholinergic load. One 72-year-old woman I know was taking three different products-all with diphenhydramine-and ended up in the ER with confusion and urinary retention. She didn’t know they all had the same active ingredient.

Even common heartburn meds like ranitidine (Zantac) are now pulled from shelves, but older versions of H2 blockers can still interact dangerously with blood thinners. And don’t forget muscle relaxants like cyclobenzaprine. They’re often prescribed for back pain, but they cause dizziness, falls, and confusion in seniors. Physical therapy and heat packs often work better.

How to Review Your Medications (Step by Step)

You don’t need to be a doctor to protect yourself or a loved one. Here’s how to do a real, effective medication review:

1. Collect every pill, patch, and liquid. Do a “brown bag review.” Empty everything from the medicine cabinet into a bag-prescriptions, OTCs, vitamins, supplements. Don’t leave anything out.
2. Bring it to your doctor or pharmacist. Ask: “Which of these are on the Beers Criteria list?” Don’t be shy. Most doctors don’t know all 30+ high-risk drugs by heart, but pharmacists do.
3. Ask about anticholinergic burden. Request the Anticholinergic Cognitive Burden (ACB) score for each drug. Add them up. If the total is 3 or higher, you’re at high risk for memory problems.
4. Check kidney function. Ask for your eGFR number. If it’s below 60, many drugs (like nitrofurantoin or metformin) need dose changes or replacement.
5. Ask for alternatives. “Is there a safer option?” is the most powerful question you can ask. For insomnia, ask about CBT-I. For pain, ask about acetaminophen or physical therapy. For anxiety, ask about talk therapy before benzodiazepines.
6. Don’t stop cold turkey. Some drugs, like benzodiazepines or antidepressants, need to be tapered slowly. Ask for a plan. Sudden withdrawal can cause seizures or rebound anxiety.

What Works Better Than High-Risk Drugs

The good news? There are safer, often more effective options for almost every high-risk medication.

• For sleep: Skip zolpidem. Try melatonin (3 mg at bedtime), CBT-I, or trazodone (50 mg). CBT-I has been shown to work better than pills long-term.
• For diabetes: Skip glyburide. Use metformin, GLP-1 agonists like semaglutide, or glipizide. These don’t cause dangerous low blood sugar.
• For allergies: Skip diphenhydramine. Use loratadine, cetirizine, or fexofenadine. They don’t cross the blood-brain barrier.
• For nausea: Skip promethazine. Use ondansetron. It’s not sedating and doesn’t cause muscle rigidity.
• For anxiety or agitation: Skip benzodiazepines like lorazepam. Try SSRIs, cognitive behavioral therapy, or environmental changes-like reducing noise or improving lighting.

What Health Systems Are Doing About It

It’s not just up to you. The system is slowly changing.

In 2024, Medicare Advantage plans started tying 5% of their quality bonuses to reducing high-risk prescriptions. Pharmacies now use real-time alerts when a doctor tries to prescribe zolpidem or glyburide to a senior. Electronic health records like Epic and Cerner now flag Beers Criteria drugs automatically.

Pharmacists are now part of the care team in many clinics. One study showed that when a clinical pharmacist reviews a senior’s meds, high-risk drug use drops by 35% in six months.

But these tools only work if you’re aware of them. If your doctor doesn’t mention medication safety, ask. If your pharmacist doesn’t review your list, request it.

What to Do If You’re Already on a High-Risk Drug

If you’re taking one of these drugs right now, don’t panic. But don’t ignore it either.

Start by writing down:

• Why you were prescribed it
• How long you’ve been taking it
• Any side effects you’ve noticed (dizziness, confusion, constipation, falls)
• Whether you’ve ever been told there’s a safer option

Then schedule a 15-minute chat with your doctor. Say: “I’ve been reading about the Beers Criteria. I’m on [drug name]. Is there a safer alternative? Can we try to reduce or switch?”

Many seniors feel guilty about questioning their doctor. But the truth is, your safety is your right. And most doctors appreciate the conversation.

Final Thought: Medication Review Isn’t a One-Time Task

Your body changes. Your health changes. Your meds should change too.

A medication review isn’t something you do once a year. It’s something you do every time you see a new doctor, start a new treatment, or feel off. If you’re on five or more drugs, make it a habit-every six months.

The goal isn’t to cut pills. It’s to keep you safe, sharp, and strong. You’ve earned that.