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 problem-but because of a medication they were told was safe. In fact, high-risk medications are one of the leading causes of preventable hospitalizations in people over 65. The good news? Many of these risks are avoidable. The key is knowing which drugs to question, when to review them, and what safer options exist.

Why Seniors Are at Higher Risk

As we age, our bodies change in ways that make medications behave differently. The liver and kidneys don’t process drugs as efficiently. Muscle mass decreases, fat increases, and the brain becomes more sensitive to sedatives. These changes mean a dose that was fine at 50 might be dangerous at 75.

On top of that, many older adults take multiple medications-sometimes five, ten, or more. This is called polypharmacy. According to the CDC, about 40% of seniors take five or more prescription drugs. Each extra pill increases the chance of dangerous interactions, side effects, or confusion. A 2022 study found that nearly one in three hospital admissions for seniors was linked to medication problems.

The Beers Criteria: The Gold Standard for Safe Prescribing

The American Geriatrics Society (AGS) created the Beers Criteria to help doctors and pharmacists identify drugs that are more harmful than helpful for older adults. First published in 1991, it’s updated every two years. The latest version came out in May 2023. It’s not a list of banned drugs-it’s a guide to when the risks outweigh the benefits.

Doctors, pharmacists, and Medicare plans use this list every day. In fact, 98% of Medicare Advantage plans use the Beers Criteria to decide which drugs to cover and under what conditions. If a drug is flagged, your doctor may need to explain why it’s still necessary.

Top 5 High-Risk Medications for Seniors (and Safer Alternatives)

Here are five of the most common high-risk drugs-and what to ask your doctor about instead.

1. Zolpidem (Ambien®) and Other Sleep Pills

Many seniors turn to sleep aids like zolpidem, eszopiclone, or zaleplon. But these drugs don’t just help you sleep-they can leave you groggy, confused, or even sleepwalking the next day. Studies show they increase the risk of falls by 82%. Hip fractures from these falls can be life-changing.

Safer alternatives: Trazodone (used off-label for sleep), cognitive behavioral therapy for insomnia (CBT-I), or simple sleep hygiene changes like avoiding screens before bed and keeping a consistent schedule. CBT-I has been shown to be more effective long-term than pills-with no side effects.

2. Glyburide (Diabeta®) for Diabetes

Glyburide is an older type of diabetes medication that stays in the body too long. This makes it easy to drop blood sugar too far-especially at night. In seniors, glyburide causes severe low blood sugar (hypoglycemia) in nearly 30% of users. That’s more than double the rate of newer drugs like glipizide.

Low blood sugar can mean confusion, fainting, seizures, or even coma. The FDA added a strong warning to glyburide labels in June 2023. Many health plans, including Buckeye Health Plan, now require prior authorization before prescribing it to anyone over 65.

Safer alternatives: Metformin, GLP-1 agonists (like semaglutide), or glipizide. These drugs are less likely to cause dangerous lows and often come with extra benefits like weight loss or heart protection.

3. Diphenhydramine (Benadryl®) and Other Anticholinergics

You’ve probably seen diphenhydramine on the shelf labeled as "sleep aid" or "allergy relief." It’s cheap and widely available. But it’s also one of the worst offenders for seniors.

This drug blocks acetylcholine-a chemical the brain needs to think clearly. Long-term use (over 1,095 doses total) increases dementia risk by 54%, according to a major study in JAMA Internal Medicine. Even short-term use can cause dizziness, dry mouth, constipation, and urinary retention.

Safer alternatives: For allergies, try loratadine (Claritin®) or cetirizine (Zyrtec®). For sleep, avoid anticholinergics entirely. For overactive bladder, consider mirabegron instead of oxybutynin.

4. Nitrofurantoin (Macrobid®) for UTIs

This antibiotic is often prescribed for urinary tract infections. But if your kidneys aren’t working well-which is common after 65-it can build up in your lungs and cause serious, sometimes fatal, damage.

Patients with even mild kidney decline (eGFR below 60) are at 12.8 times higher risk of lung toxicity. In some cases, this leads to permanent scarring or breathing failure.

Safer alternatives: Fosfomycin, nitroxoline, or trimethoprim (if kidney function is normal). Always ask your doctor to check your kidney numbers before starting any antibiotic.

5. Alpha-1 Blockers (Doxazosin, Terazosin)

These drugs were once popular for high blood pressure and prostate issues. But they cause a sudden drop in blood pressure when standing up-called orthostatic hypotension. In seniors over 75, this happens in nearly 25% of users. That’s more than three times the rate of safer blood pressure drugs like chlorthalidone.

The result? Dizziness, fainting, and falls. One study found these drugs triple the risk of syncope (passing out) compared to other hypertension treatments.

Safer alternatives: ACE inhibitors (like lisinopril), ARBs (like losartan), or thiazide diuretics. These work just as well without the dizzying side effects.

How to Review Your Medications

You don’t need to wait for a crisis to act. Here’s how to take control:

• Do a "brown bag" review: Bring all your pills, supplements, and OTC meds to your doctor or pharmacist. Don’t leave anything out-even herbal teas or CBD gummies.
• Ask about anticholinergic burden: Request a score from the Anticholinergic Risk Scale (ARS). A score above 3 means high risk. Many drugs add up-even if they seem harmless alone.
• Check for duplication: Are you taking two drugs that do the same thing? For example, one for sleep and one for anxiety that both cause drowsiness?
• Ask: "Is this still needed?" Many drugs are prescribed for short-term use but kept for years. Ask if you can try stopping one at a time.
• Use the Beers Criteria: Look up the list yourself at geriatricscareonline.org. You don’t need to be an expert to understand it.

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

Don’t stop cold turkey. Some drugs, like benzodiazepines or long-term sleep aids, can cause seizures or severe withdrawal if stopped suddenly.

Work with your doctor to taper slowly. For example:

• Reduce zolpidem by 50% every two weeks.
• Switch from glyburide to glipizide over 2-4 weeks.
• Replace diphenhydramine with a non-anticholinergic option.

Studies show that when pharmacists lead these transitions, high-risk drug use drops by over 34% in six months. Don’t be afraid to ask for a medication review appointment. Medicare covers these for beneficiaries enrolled in Medication Therapy Management (MTM) programs.

What’s Changing in 2024

New rules are pushing the system toward safer prescribing:

• The CMS Innovation Center now ties 5% of Medicare Advantage bonus payments to reducing high-risk drug use.
• Epic and Cerner-two of the biggest electronic health record systems-have updated their alerts to flag Beers Criteria drugs the moment a doctor tries to prescribe them to someone over 65.
• Pharmacies using Surescripts now show real-time alerts: "This drug is high-risk for seniors. Consider alternatives."

These aren’t just tech upgrades-they’re saving lives. One pilot program saw a 19% drop in dangerous prescriptions just from these alerts.

What You Can Do Today

You don’t need to be a doctor to protect yourself or a loved one. Start with this:

1. Make a list of every medication you take-prescription, over-the-counter, and supplements.
2. Check if any are on the 2023 Beers Criteria list.
3. Ask your pharmacist to run an anticholinergic burden check.
4. Request a medication review during your next appointment.
5. Bring this article with you. It’s a conversation starter.

Many seniors are unaware that safer options exist. One survey found that 58% of seniors using high-risk drugs had never been told about alternatives. Don’t be one of them. Your next healthy, fall-free year starts with a simple question: "Is this still right for me?"