Fall Risk in Older Adults on Sedating Antihistamines: What to Do Now

Every year, more than 36 million falls happen among older adults in the U.S. alone. About 1 in 4 of them happen because of a medication they didn’t realize was risky. One of the most common culprits? Over-the-counter antihistamines like diphenhydramine - the active ingredient in Benadryl, NyQuil, and many sleep aids. It’s sold on every pharmacy shelf, marketed as harmless, and taken by millions of older adults for allergies, colds, or trouble sleeping. But for people over 65, these drugs aren’t just outdated - they’re dangerous.

Why Sedating Antihistamines Are a Hidden Fall Hazard

First-generation antihistamines - diphenhydramine, chlorpheniramine, brompheniramine - were designed in the 1940s to block histamine and stop sneezing. But they don’t stop there. Unlike newer versions, they easily slip through the blood-brain barrier and depress the central nervous system. That’s why they make you drowsy. And for older adults, that drowsiness doesn’t just mean a nap. It means slower reactions, wobbly balance, blurred vision, and delayed thinking - all ingredients for a fall.

Here’s what the science says: A 2018 meta-analysis in Osteoporosis International found that older adults taking first-generation antihistamines had a 54% higher risk of falling and breaking a bone. A 2025 study in the Journal of the American Geriatrics Society tracked nearly 200,000 older adults and found that 8% of those who filled a prescription for a vestibular suppressant (like these antihistamines) fell within 60 days. That’s not a coincidence. It’s a pattern.

Why does this happen more in older people? Because aging changes how the body handles drugs. The liver and kidneys don’t clear medications as quickly. A healthy 30-year-old might process diphenhydramine in 8.5 hours. An 80-year-old? It can take over 13 hours. That means the drug lingers, sedating them through the day - even if they took it the night before.

The Shocking Truth About OTC Use

Most people don’t think of Benadryl as a medication that needs a doctor’s approval. It’s just a shelf item. But the American Geriatric Society labeled these drugs as “potentially inappropriate” for older adults in their Beers Criteria - and they’ve kept that warning strong in every update since 2019. Still, sales data from IQVIA shows that 28.7 million units of diphenhydramine were sold in 2024 to people aged 65 and older. That’s more than 100,000 doses per day, just in the U.S.

And here’s the real problem: the same dose that’s fine for a 40-year-old can be too much for an 80-year-old. A 25 mg tablet of diphenhydramine might be standard on the label - but for seniors, even 12.5 mg can cause dizziness, confusion, or unsteadiness. And because it’s sold without a prescription, most older adults never talk to a doctor about it. They just grab it when they feel itchy, stuffy, or sleepless.

Second-Generation Antihistamines: The Safer Choice

Not all antihistamines are created equal. Second-generation options - like loratadine (Claritin), cetirizine (Zyrtec), and fexofenadine (Allegra) - were developed to avoid the brain. They don’t cross the blood-brain barrier the same way. That means they treat allergies without the drowsiness.

Studies show a clear difference:

• Diphenhydramine causes drowsiness in 15-20% of users.
• Fexofenadine causes drowsiness in only 6%.
• Cetirizine causes drowsiness in 14% - still higher than fexofenadine, but far lower than diphenhydramine.

On the Anticholinergic Cognitive Burden Scale - a tool doctors use to rate how much a drug affects thinking and balance - diphenhydramine scores a 4 (strong). Fexofenadine? A 0. That’s the difference between a drug that increases fall risk and one that doesn’t.

A 2025 study found that switching from a first-generation antihistamine to a second-generation one reduced fall risk by 42%. That’s not a small improvement. That’s life-changing.

What to Do If You’re Taking One Right Now

If you or someone you care about is taking diphenhydramine or chlorpheniramine - even just once a week - here’s what to do:

1. Don’t quit cold turkey. Stopping suddenly can make allergy symptoms worse or cause rebound insomnia. Work with a doctor or pharmacist.
2. Switch to fexofenadine. It’s the safest option. No sedation. No dizziness. No anticholinergic burden. Available over-the-counter. Often cheaper than brand-name options.
3. Reduce the dose. If you must keep using diphenhydramine temporarily, cut it to 12.5 mg - not 25 mg. And take it at night, not in the morning.
4. Review all medications. Many older adults take multiple sedating drugs - antihistamines, sleep aids, anxiety meds, painkillers. Together, they multiply the risk. A full medication review can cut fall risk by up to 26%.

Ask your pharmacist for a “brown bag review”. Bring every pill, supplement, and OTC bottle to the pharmacy. Pharmacists are trained to spot dangerous combinations. In one study, they found an average of 3.2 high-risk medications per older adult - many of them antihistamines.

Non-Medication Alternatives That Actually Work

You don’t need a pill to manage allergies or sleep. Here are proven, drug-free options:

• Nasal saline rinses - reduce allergy symptoms by 35-40%. Use a neti pot or squeeze bottle daily.
• Allergen-proof bedding - covers for pillows and mattresses cut dust mite exposure by 83%.
• HEPA air purifiers - remove 99.97% of airborne allergens. A simple one in the bedroom makes a big difference.
• Sleep hygiene - if you’re using diphenhydramine for sleep, replace it with a consistent bedtime, no screens after 9 p.m., and a cool, dark room. Studies show these changes work better than sleep aids in older adults.

These aren’t just “nice to have.” They’re evidence-backed, safe, and free - or low-cost - alternatives that don’t carry the risk of a fall.

Environmental Changes That Prevent Falls

Even if you switch medications, your home might still be a fall hazard. The CDC’s STEADI initiative says you can reduce falls by 30% just by fixing your environment:

• Install grab bars in the bathroom - cuts fall risk by 28%.
• Improve lighting - especially hallways and stairs - reduces falls by 32%.
• Remove loose rugs and cords - these cause half of all home falls.
• Add non-slip mats in the shower and near the sink.

These changes cost less than $100 and take a weekend. They’re not glamorous - but they save lives.

What’s Changing in 2026?

Change is coming. Since 2024, Medicare’s Annual Wellness Visit now requires doctors to review high-risk medications - including antihistamines - as part of the fall risk check. The CDC updated its STEADI toolkit in January 2025 to include a specific module for sedating meds. The American Academy of Neurology now advises doctors to avoid vestibular suppressants entirely in anyone with a history of falls.

Even better: Two new antihistamines are in Phase II trials - AGS-2025-01 and FEX-AGE-101 - designed specifically for older adults. Early results show an 89% drop in drowsiness compared to diphenhydramine. They’re not on the market yet, but they’re proof that science is finally catching up.

Final Takeaway: It’s Not Too Late

Many older adults think, “I’ve been taking this for years - it’s fine.” But the body changes. What was safe at 60 isn’t safe at 75. And every fall isn’t just a bruise - it’s a broken hip, a hospital stay, a loss of independence.

You don’t need to suffer through allergies or sleepless nights. You don’t need to rely on a drug that’s been flagged by every major geriatric organization. You just need to ask: Is this really the best option?

Switch to fexofenadine. Talk to your pharmacist. Clean up your home. Try saline rinses. These steps don’t cost much. But they might save your life - or someone else’s.