The Tablets Nobody Reviewed

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The problem isn’t the drugs — it’s the absence of a review

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Most medication harm in older people doesn’t come from a dangerous prescription. It comes from a reasonable prescription that was never revisited after the reason for it passed.

Three things change with age and none of them are visible from the outside. Kidneys and liver clear drugs more slowly, so a dose that was correct at 50 accumulates at 75. The ageing brain is more sensitive to sedation. And each additional medication multiplies the interactions rather than adding to them.

The recurring endpoint is a fall. A drug that makes a 40-year-old slightly woozy puts an 80-year-old on the floor, and a fractured hip is frequently where independence ends. That mechanism is why the list below is dominated by sedatives rather than by anything exotic.

There’s an official reference for this. The American Geriatrics Society Beers Criteria, updated in 2023, is an explicit list of medications generally best avoided in adults 65 and over. Nearly everything below appears in it.

The seven worth asking about

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1. Z-drugs — zopiclone, zolpidem (Ambien). Prescribed readily for poor sleep. In older people they raise the risk of falls, fractures, daytime confusion and dependence, while the sleep they add is measured in minutes rather than hours. A modest benefit against a serious risk.

2. Benzodiazepines — diazepam, lorazepam. Genuinely useful through an acute crisis. Taken long-term in an older body they produce heavy sedation, memory problems and unsteadiness, and they are among the most dependence-forming drugs in common use. Never stopped abruptly — withdrawal can include seizures.

3. Older antihistamine sleep aids — diphenhydramine (Benadryl, Nytol). The one people assume is safe because it’s on a supermarket shelf. It’s strongly anticholinergic: confusion, blurred vision, constipation, falls.

And the dementia signal is real. Gray et al. (2015, JAMA Internal Medicine) followed 3,434 adults aged 65+ for around a decade, tracking ten years of prescription records; roughly 800 developed dementia. Cumulative anticholinergic exposure showed a dose-response relationship with dementia risk — the highest-use group, equivalent to daily diphenhydramine for three years or more, carried a 54% increased risk versus minimal use. The National Institute on Aging’s summary notes the study also suggested the risk may persist after stopping.

Observational data can’t prove causation, and reverse causation is worth considering — early dementia could plausibly cause the insomnia that leads to the tablets. But the dose-response gradient makes that explanation harder to sustain.

4. Hydrochlorothiazide. A blood-pressure water tablet that can tip an older person into dehydration and pull electrolytes out of balance — low potassium, low sodium — producing dizziness, weakness and falls. Particularly risky during illness, hot weather, or poor fluid intake. Safer alternatives exist and long-term use warrants monitoring.

5. Gabapentin and pregabalin (Neurontin, Lyrica). For nerve pain, and increasingly prescribed for pain they may not touch. Dizziness, drowsiness, mental fog and unsteadiness in older people, and combined with other sedating drugs they can dangerously depress breathing. The question worth asking is whether the pain is genuinely better, or the person is simply more sedated.

6. Proton pump inhibitors — omeprazole, lansoprazole, pantoprazole. Not acutely dangerous. The issue is that they are started as a short course and continued for years unreviewed. Long-term use is associated with low vitamin B12, low magnesium, and reduced bone density with more fractures. Stopping abruptly causes rebound acid production that is often worse than the original problem, which is exactly why it needs tapering rather than a decision made at home.

7. NSAIDs — ibuprofen, naproxen, diclofenac. Sold everywhere and treated as harmless. Taken regularly by an older person this is among the riskiest items here: stomach bleeding, kidney injury (worse if dehydrated or on other kidney-affecting drugs), and raised blood pressure carrying higher heart attack and stroke risk. An occasional dose is usually fine. More than about a week of regular use for general aches is a conversation.

What to actually do about it

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The term for the fix is deprescribing — safely stopping medications that are no longer earning their place, by tapering gradually under supervision. It is not “fewer tablets” as a goal in itself. It’s the right tablets, at the right dose, for the person as they are now rather than as they were when the prescription started.

Do not stop anything on the strength of this article. Several of these cause dangerous withdrawal or rebound. This is not an emergency and it doesn’t need to be handled today.

Summary

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Medication harm in older adults is usually cumulative and silent, and it usually traces back to a prescription nobody revisited. Age slows drug clearance, increases sensitivity to sedation, and multiplies interactions — and the common endpoint is a fall. Seven categories carry disproportionate risk: Z-drugs, benzodiazepines, anticholinergic antihistamines, hydrochlorothiazide, gabapentinoids, long-term PPIs, and regular NSAIDs. The anticholinergic-dementia association is dose-dependent and substantial, at 54% higher risk in the heaviest-use group.

What to actually do:

1. Book a medication review with a GP or pharmacist — this is a specific appointment type, not a favour to ask.
2. Bring every box, including the over-the-counter ones. Nytol and ibuprofen won’t be on the prescription list and belong in the conversation.
3. Ask one question per medication: is this still needed at my age, and do the benefits still outweigh the risks?
4. Replace the antihistamine sleep aid first if one is in use. It’s the item most likely to be self-prescribed and least likely to have been discussed.
5. Taper, never stop abruptly — benzodiazepines, gabapentinoids and PPIs all need it.
6. Ask about monitoring if long-term PPIs or hydrochlorothiazide continue — B12, magnesium and electrolytes respectively.

Sources & further reading

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• 2023 American Geriatrics Society Beers Criteria® Update Expert Panel, American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults, Journal of the American Geriatrics Society (2023) — Wiley / PubMed / full PDF
• Gray S.L. et al., Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study, JAMA Internal Medicine (2015) — JAMA Internal Medicine / PubMed
• National Institute on Aging, Use of anticholinergic drugs linked to higher dementia risk — NIA
• Kaiser Permanente Washington Health Research Institute, Higher dementia risk linked to more use of common drugs — KPWHRI
• AHRQ Patient Safety Network, AGS 2023 updated Beers Criteria — PSNet