Alpha adrenergic blockers Adrenergic blockers High blood pressure is very common. It often does not cause symptoms; however, high blood pressure can increase the risk of stroke, heart attacks, and heart failure. Therefore, it is important... read more for treatment of high blood pressure (such as doxazosin, prazosin, and terazosin)
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 Adrenergic blockers High blood pressure is very common. It often does not cause symptoms; however, high blood pressure can increase the risk of stroke, heart attacks, and heart failure. Therefore, it is important... read more (such as clonidine, guanabenz, guanfacine, methyldopa, and reserpine)
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.
Methyldopa and reserpine may contribute to depression.
Reserpine can contribute to erectile dysfunction (impotence).
Meperidine, an opioid, often causes confusion and can sometimes cause seizures. Like all opioids, it may cause constipation, retention of urine, drowsiness, and confusion. When taken by mouth, meperidine is not very effective.
Amiodarone usually should not be a first choice to treat atrial fibrillation (an abnormal heart rhythm) except in special circumstances.
Amiodarone may increase the risk of thyroid disorders, lung disorders, and long QT syndrome (which itself can contribute to serious abnormal heart rhythms).
Antidepressants Drug Treatment for Depression Agomelatine, a new type of antidepressant, is a possible treatment for major depressive episodes. Several types of drugs can be used to treat depression: Selective serotonin reuptake inhibitors... read more (older ones, such as amitriptyline, amoxapine, clomipramine, desipramine, doxepin at high doses, imipramine, nortriptyline, paroxetine, protriptyline, and trimipramine)
These older antidepressants have strong anticholinergic effects.* They also increase risk of falls, constipation, dry mouth, excessive drowsiness, and abnormal heart rhythms.
Antihistamines Antihistamines Allergic reactions (hypersensitivity reactions) are inappropriate responses of the immune system to a normally harmless substance. Usually, allergies make people sneeze; the eyes water and itch... read more (older ones) that have anticholinergic effects* (such as brompheniramine, carbinoxamine, chlorpheniramine, clemastine, cyproheptadine, dexbrompheniramine, dexchlorpheniramine, dimenhydrinate, diphenhydramine, doxylamine, hydroxyzine, meclizine, promethazine, and triprolidine)
To relieve allergy Overview of Allergic Reactions Allergic reactions (hypersensitivity reactions) are inappropriate responses of the immune system to a normally harmless substance. Usually, allergies make people sneeze; the eyes water and itch... read more or cold Common Cold The common cold is a viral infection of the lining of the nose, sinuses, and throat. Many different viruses cause colds. Usually, colds are spread when a person's hands come in contact with... read more 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.
More effective drugs are available.
Benztropine and trihexyphenidyl have strong anticholinergic effects.*
Antipsychotic drugs Antipsychotic drugs Schizophrenia is a mental disorder characterized by loss of contact with reality (psychosis), hallucinations (usually, hearing voices), firmly held false beliefs (delusions), abnormal thinking... read more (such as chlorpromazine, haloperidol, thiothixene, risperidone, olanzapine, quetiapine, and aripiprazole)
To treat loss of contact with reality (psychosis Diagnosis Delirium is a sudden, fluctuating, and usually reversible disturbance of mental function. It is characterized by an inability to pay attention, disorientation, an inability to think clearly... read more ) or, somewhat controversially, to treat behavioral disturbances in people with dementia Dementia Dementia is a slow, progressive decline in mental function including memory, thinking, judgment, and the ability to learn. Typically, symptoms include memory loss, problems using language and... read more
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
Metoclopramide can cause drowsiness and movement disorders (that resemble Parkinson disease Parkinson Disease (PD) Parkinson disease is a slowly progressive degenerative disorder of specific areas of the brain. It is characterized by tremor when muscles are at rest (resting tremor), increased muscle tone... read more ). In general, metoclopramide should not be used longer than 3 months.
Barbiturates (such as amobarbital, butabarbital, butalbital, mephobarbital, pentobarbital, phenobarbital, and secobarbital)
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 Treatment Generalized anxiety disorder consists of excessive nervousness and worry about a number of activities or events. People have anxiety more days than not over a period of 6 months or longer. People... read more (such as alprazolam, chlordiazepoxide, chlordiazepoxide with amitriptyline, clidinium with chlordiazepoxide [alone or in combination with amitriptyline or clidinium], clonazepam, clorazepate, diazepam, estazolam, flurazepam, lorazepam, oxazepam, quazepam, temazepam, and triazolam)
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.
Certain hypnotic drugs (such as eszopiclone, zaleplon, and zolpidem)
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
Desmopressin has a high risk of causing hyponatremia Hyponatremia (Low Level of Sodium in the Blood) In hyponatremia, the level of sodium in blood is too low. A low sodium level has many causes, including consumption of too many fluids, kidney failure, heart failure, cirrhosis, and use of diuretics... read more (low level of sodium in the blood). Desmopressin should not be used for treatment of excessive urination at night because there are safer alternatives.
To treat heart failure Heart Failure (HF) Heart failure is a disorder in which the heart is unable to keep up with the demands of the body, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs, and/or... read more or abnormal heart rhythms Overview of Abnormal Heart Rhythms Abnormal heart rhythms (arrhythmias) are sequences of heartbeats that are irregular, too fast, too slow, or conducted via an abnormal electrical pathway through the heart. Heart disorders are... read more (arrhythmias)
As people age, the kidneys are less able to remove digoxin from the body. Large doses of the drug can more easily reach harmful (toxic) levels. Side effects may include loss of appetite, nausea, and confusion.
Dipyridamole frequently causes low blood pressure when standing up in older people. It can also increase the risk of bleeding when it is taken with other drugs that make blood less likely to clot, such as aspirin or the anticoagulant warfarin.
Drugs that reduce or stop muscle spasms in the digestive tract (antispasmodic drugs, such as atropine [except for eye drops], belladonna alkaloids, clidinium/chlordiazepoxide, dicyclomine homatropine [except for eye drops], hyoscyamine, methscopolamine, propantheline, and scopolamine)
To relieve abdominal cramps Chronic Abdominal Pain and Recurring Abdominal Pain Chronic abdominal pain is pain that is present for more than 3 months. It may be present all the time (chronic) or come and go (recurring). Chronic abdominal pain usually occurs in children... read more and pain Pain read more
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.
Ergot mesylate and isoxsuprine
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 Symptoms Menopause is the permanent end of menstrual periods and thus of fertility. For up to several years before and just after menopause, estrogen levels fluctuate widely, periods become irregular... read more , 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) blockers (such as cimetidine, famotidine, nizatidine, and ranitidine)
To treat heartburn (acid reflux Gastroesophageal Reflux Disease (GERD) In gastroesophageal reflux disease, stomach contents, including acid and bile, flow backward from the stomach into the esophagus, causing inflammation in the esophagus and pain in the bottom... read more ), indigestion Indigestion Indigestion is pain or discomfort in the upper abdomen. People may also describe the sensation as gassiness, a sense of fullness, or gnawing or burning. The sense of fullness may occur after... read more , or ulcers Peptic Ulcer Disease A peptic ulcer is a round or oval sore where the lining of the stomach or duodenum has been eaten away by stomach acid and digestive juices. Peptic ulcers can result from Helicobacter pylori... read more
Typical doses of cimetidine may have drug interactions and cause side effects, especially confusion.
To some extent, high doses of famotidine, nizatidine, and ranitidine may cause side effects, especially confusion.
These drugs may worsen memory and thinking problems in people with cognitive impairment.
Insulin Insulin Replacement Therapy Many people with diabetes require drugs to lower blood glucose levels, relieve symptoms, and prevent complications of diabetes. There are two types of diabetes mellitus Type 1, in which the... read more given by a sliding scale (insulin regimens containing only short- or rapid-acting insulin dosed according to current blood sugar [glucose] levels, unless used with a longer-acting insulin)
When given this way, insulin can cause dangerously low blood sugar and is not more effective at controlling diabetes than fixed doses of insulin given with meals.
When taken by mouth, mineral oil may be accidentally inhaled into the lungs, which can cause lung damage.
Male sex hormones (such as testosterone and methyltestosterone)
These hormones should be used only if a man's testosterone levels are low and causing significant symptoms. Use of these hormones may contribute to heart disorders and worsen prostate disorders (avoid in men with prostate cancer).
To increase appetite and help regain lost weight
Megestrol can cause blood clots and possibly increase the risk of death and is typically not very effective in helping people gain weight.
Muscle relaxants (such as carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, and orphenadrine)
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.
Nifedipine (immediate release)
Nifedipine, if taken in immediate-release capsule form, may decrease blood pressure too much, sometimes causing symptoms similar to those of a heart attack (for example, chest pressure and chest pain).
With long-term use, nitrofurantoin can cause side effects (such as lung damage). When taken to treat a bladder infection, it may not be effective if kidney function is reduced.
NSAIDs (such as aspirin, diclofenac, diflunisal, etodolac, fenoprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, and tolmetin)
COX-2 inhibitors (celecoxib)
Long-term use of NSAIDs may cause peptic ulcer disease, or bleeding from the stomach or intestine unless another drug is also given to protect the stomach. NSAIDs and celecoxib can also worsen kidney function and symptoms of heart failure.
Of all NSAIDs, indomethacin has the most side effects. It can also cause confusion or dizziness.
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 Clostridium difficile infection, bone loss and fractures, and vitamin B12 deficiency.
Sulfonylurea drugs (long-acting ones, such as chlorpropamide, glimepiride, and glyburide [also known as glibenclamide])
The effects of chlorpropamide last a long time. In older people, these drugs can cause low blood sugar levels (hypoglycemia Hypoglycemia Hypoglycemia is abnormally low levels of sugar (glucose) in the blood. Hypoglycemia is most often caused by drugs taken to control diabetes. Much less common causes of hypoglycemia include other... read more ) for many hours. Chlorpropamide can also cause the kidneys to retain too much water, lowering the sodium level in the blood.
Glyburide and glimepiride can also cause low blood sugar levels for many hours.
* Anticholinergic effects Anticholinergic: What Does It Mean? Drugs, the most common medical intervention, are an important part of medical care for older people. Without drugs, many older people would function less well or die at an earlier age. Older... read more include confusion, blurred vision, constipation, dry mouth, light-headedness and loss of balance, and difficulty starting to urinate.
† Dipyridamole is also available in an extended-release formulation with aspirin. This product, which is used to prevent strokes in people who have had a stroke, is not included in this list.
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